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GETTING TO KNOW YOUR INAUGURAL HAITI HEALTH DEFINING LEADERSHIP CONTINUIN 


NEW NPN CHAIRS MISSION C people Would ansv\ EDUCATION 
Kristen Dominik, PharmD & P. Tin An Academic-Community and Ney KNOW what leadership Ik Nev \ 
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MARYLAND PHARMACISTS ASSOCIATION JOURNAL | FALL 2014 


77 | PRESIDENT’S PAD 


As you may 

have heard, the 
Association is now 
the proud owner 
of a building in 
Columbia.This is 

a huge step for 

the future of the 
Association and we 
are very excited to 
be moving forward. 


Maes fh 


2 MH MARYLAND PHARMACIST | | 


Dear Members, 


There is a lot going on during our Board 
of Trustee meetings and we have already 
had a couple of late nights this year. 

Our August meeting was our Board 
Orientation so the existing and new 
board members would have a better 
understanding of the responsibilities 
required of them as board members. Our 
September meeting gave our committee 
chairs an opportunity to share their goals 
and action plan for their committees to 
finish up our last year on our Strategic 
Plan. As the year moves on, the Board 
will make plans to hold our next Strategic 
Planning session in the spring to position 
our Association to hit the ground running 
at Convention 2015. 


As you may have heard, the Association 
is now the proud owner of a building 

in Columbia. We have formed the EFK 
Properties, LLC and that entity purchased 
9115 Guilford Road. There are three 
tenants to the building including MPhA 
occupying one of the three spaces. Your 
MPhA board members have learned a 
lot more about mortgages, insurance 
policies, leases, inspections, and building 
plans than we ever thought we needed 
to know. They certainly did not teach this 
in pharmacy school! This is a huge step 
for the future of the Association and we 
are very excited to be moving forward. 
The building plans will be available to the 
membership and please be looking for 
announcements on how you can be a 
part of this exciting endeavor. 


Our Selection Committee is working hard 
to find the right person for our Executive 
Director position. The candidates have 
been screened and initial interviews have 
been completed. There should be an 
announcement soon as to the new leader 
for our Association. We are excited for the 
possibilities that will come from having 
this important position filled. 


These are big changes for the 
Association, however, we continue to 


take care of the regular business of 
realizing our mission. Our Association 
has also led the discussion process for 
developing the process required for 
community pharmacists to gain access 
to the full data available on the CRISP 
website. All pharmacists are currently 
available to register for access to the 
PDMP data available on CRISP. If you 
have not yet done so, please register at 
www.crisphealth.org. Many pharmacists 
use the available information on CRISP 
when dispensing controlled substance 
prescriptions. We are excited about the 
possibility of pharmacists having access 
to lab values and hospitalization records 
for the first time in a community setting. 
MPhA is working with the other state 
organizations to make this a reality. 


October is American Pharmacists Month 
and MPhA is celebrating! We have a lot 
of activities planned and many will have 
already occurred by the time this letter 
goes out. We hope that you have had a 
chance to take advantage of some of the 
CE programming, community events, and 
even the Tweet-A-Thon! A big thank you 
to Nicole Culhane and her committee for 
coordinating the activities. 


There is more information in Dixie's 
Interim Executive Director Message so 
| encourage you to read that as well. 
As you know, | have continued past 
my scheduled term as your President. 
| want to thank you for the opportunity 
that | have had in continuing to move 
our Association forward. As | transition 
to Chair of the Board, | look forward to 
serving you in a different position and 
look forward to seeing you at a meeting 
Or event soon! 


Sincerely, 


O bristiente.- DLoon9 


Christine Lee-Wilson, PharmD 
President 


MARYLAND PHARMACIST 


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FEATURES 


Al A Quick Year in Review — NPN 


6 Inaugural Haiti Health Mission 


1 1 Save the Date: MPhA/MD-ASCP/MPhS Mid-Year Meeting 


1 WZ Defining Leadership 


1 Al Med-Check Toolkit 


DEPARTMENTS 


2 President's Pad 

7 Welcome New Members 
7 Corporate Sponsors 
Member Mentions 
Continuing Education 
CE Quiz 

Executive Director's 
Message 


6 
11 
18 
21 
26 
28 


FALL 2014 


ADVERTISERS INDEX 


McKesson 

Nutramax 

Cardinal Health 
Buy-Sell-A-Pharmacy 
HD Smith 


Pharmacists Mutual 
Companies 


MPhA OFFICERS 2014-2015 
Brian Hose, PharmD, Chairman of the Board 
Christine Lee-Wilson, PharmD, President 

Hoai-An Truong, PharmD, Vice President 

Matthew Shimoda, PharmD, Treasurer 

Lynette Bradley-Baker, PhD, RPh, Honorary President 


HOUSE OFFICERS 
G. Lawrence Hogue, BSPharm, PD, Speaker 
W. Chris Charles, PharmD, Vice Speaker 


MPhA TRUSTEES 

Nicole Culhane, PharmD, 2016 

Kristen Fink, PharmD, BCPS, CDE, 2015 

Mark Lapouraille, RPh, 2016 

Cherokee Layson-Wolf, PharmD, CGP, BCACP, FAPhA, 2017 

Ashley Moody, PharmD, 2017 

Wayne VanWie, RPh, 2015 

Nghia Nguyen, ASP Student President, Notre Dame of 
Maryland University 


EX-OFFICIO MEMBERS 
Cynthia J. Boyle, PharmD, FAPhA, Interim Dean 

University of Maryland Eastern Shore School of Pharmacy 
Natalie Eddington, PhD, Dean 

University of Maryland School of Pharmacy 
Anne Lin, PharmD, Dean 

Notre Dame of Maryland University School of Pharmacy 
David Jones, RPh, FASCP, MD-ASCP Representative 
Brian Grover, PharmD, MSHP Representative 


CONTRIBUTORS 
Kelly Fisher, Maryland Pharmacist Editor 
Marketing Coordinator 


PEER REVIEWERS 

W. Chris Charles, PharmD 

G. Lawrence Hogue, BSPharm, PD 
Hanna Salehi, PharmD Candidate, 2015 
Jackie Tran, PharmD 


Special thanks to the following contributors: 
Dixie Leikach, RPh, MBA, FACA, Interim Executive Director 
Elsie Prince, Office Manager 

Communications Committee, chaired by Cindy Thompson 
Graphtech, Advertising Sales and Design 


We welcome your feedback and ideas for future articles for 
Maryland Pharmacist. Send your suggestions to Kelly Fisher: 
Maryland Pharmacists Association, 1800 Washington Blvd., 
Ste. 333, Baltimore, MD 21230, call 410.727.0746, or email 
kelly.fisher@mdpha.com 


The Maryland Pharmacists Association (MPhA) New Practitioner Network 
(NPN) has grown drastically in the past year through the leadership of Ashley 
Moody and Deanna Tran. Several of its members have actively participated 

in and developed events that cater to both new practitioners (NPs) and 
Seasoned pharmacists alike to help Support our organization and advance our 
profession. Keeping in mind its goal of providing a venue for new practitioners 
to exchange ideas and information to further professional development 

and grow their network, NPN has provided a valuable array of the following 
activities to uphold its mission: 


e MPhA Mentorship Program — through collaboration between MPhA 
Professional Development and NPN committees 


e “Striking Out with NPN” bowling night — event for new Maryland pnarmacy 
residents and fellows 


e “Coffee & Donuts with MPhA NPN with Class of 2015" — meet and greet 
event for upcoming graduates at all three Maryland pharmacy schools 


e “Current Trends in Community, Geriatrics, and Ambulatory Care” — New 
Practitioner CE at the MPhA Mid-Year Meeting in Hyattsville, Maryland 


e Happy Hours at various restaurants around Baltimore 


e Graduation Celebration for the Class of 2014 — NPN hosted to celebrate 
new Maryland graduates from all three schools of pharmacy in Salisbury, 
Maryland 


What's in Store for the 
Year Ahead? 


Looking forward to the upcoming 
year, Kristen and Tim will be 
spearheading NPN to build upon 
its Successes from the previous 
years and to expand its gamut of 
professional relations into new 
heights. In order to further the 
mission of this committee, they 
plan on completing the following 
objectives in addition to the 
aforementioned events: 


e Dynamically engage the NPN 
committee with the other MPhA 
committees in order to ensure 
the voices of the NPs are heard, 
and collaboration with seasoned 
pharmacists is established and 
maintained 


¢ Closely work with neighboring state 
pharmacy organizations who also 
have a NPN to expand connections 
and generate more novel ideas for 
practice and professional/personal 
development 


e Proudly advocate for MPhA 
and its mission which would 
then increase membership and 
active involvement of its existing 
colleagues and newcomers 


Truly, the future of our profession 

is in good hands with these 

highly motivated and innovative 
professionals. They continue to push 
the envelope forward while assuring » 
that the advancement of the a 
profession is their top priority. 


4 MARYLAND PHARMACIST | 


NEW NPN CHAIRS 


Kristen Dominik, PharmD 


Kristen comes to the organization from Pittsburgh, Pennsylvania, 
where she will be cheering for her Pittsburgh Steelers and 
networking with all of yinz NPs with much hometown pride. She 
also is becoming an avid runner, having run a couple of half 
marathons recently. Kristen graduated in 2011 from Duquesne 
University and completed a PGY-1 community pharmacy 
residency with Walgreens and Massachusetts College of 
Pharmacy and Health Sciences. Currently, she works at United 
Healthcare as a Clinical Pharmacist, specializing in Medication 
Therapy Management. 


P. Tim Rocafort, PharmD, BCACP 


Tim comes to the organization from Lawrenceville, New Jersey, 
where he will be fist pumping for pharmacist provider status 

this year. At the same time, he enjoys a healthy dose of work-life 
balance which includes staying active outdoors and CrossFit. 

Tim graduated in 2010 from Rutgers University and completed a 
PGY-1 community pharmacy residency with Dominick's Pharmacy 
and University of Illinois at Chicago. Currently, he works at the 
University of Maryland School of Pharmacy as an Assistant 
Professor, specializing in Community Pharmacy Practice. 


For further information on the New Practitioner Network or if you 
are interested in getting involved, please email Kristen or Tim at 
kristendominik13@gmail.com or ptimrocafort@gmail.com. 


MARYLANDPHARMACIST.ORG {i 5 


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Care Pharmacies, Inc. Nutramax Laboratories, Inc. 
CVS Caremark Pharmacists Mutual Companies 
EPIC Pharmacies Inc. Rite Aid 

FreeCE.com Walgreens 


(¢ ihe to our newest members! 
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lan Cook Farideh Kashani Nwanne Udeagha 
Kenneth Ey Judy Lapinski Andrew Wherley 
Ricardo Hernandez Patrick Maney Eric Yospa 


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MARYLANDPHARMACIST.ORG {if 7 


An Academic-Community and. 
Interprofessional Collaboration 


Imagine traveling to an island in the Caribbean, seeing clear blue waters and palm 
tree-lined beaches, sensing the ocean breezes and waves and staying at a “top 
floor, waterfront condo” with meals being served three times a day. You may think, 
“Am | on a vacation or a mission?” 


During the journey on the island, and Physician Assistant Programs), e Ms. Annette Rogers, UMES Pharmacy 
eae A in an a on Curvy, organizers from the Health and Staff 

muddy, and unpaved terrain for hours, Education for Haiti, Inc. and St. Francis . 
sometimes in the rain, across a river of Assisi Church, and pharmacist Pa ees ae pee tence 
and in the night. Back at your condo, preceptor from the Indian Health 

you may flip the switch but get no Service, U.S. Public Health Service e Dr. Courtney Murphy, UMES 

light, turn the faucet but get no water, (USPHS). The interest and planning Pharmacy Alumna 

and if you are lucky enough to take Started about a year ago when Dr. e Ms. Maxine Cyprien, UMES Physician 
a shower, you become sweaty again Frank Nice, a retired captain from the Assistant Student 

minutes later. Better yet, you may USPHS and pharmacist at the U.S. ae 
enter the bathroom with a cockroach Food and site Administration, came aS Wes oe ey 
on the wall, wake up in the middle of to speak to pharmacy and physician pesistant Scent 

the night with a chicken next to you, assistant students at a Professional e Ms. Renee Lindo, UMES Physician 
and obsessively apply DEET yet still Development Seminar. After the Assistant Student 

attract hungry mosquitoes. interest was piqued, he and his co- e Ms. Kareemah Muhammed, UMES 
Does anyone want to join us for organizer, Mrs. Pat Labuda, came to Pharmacy Student 

this vacation to the Caribbean? UMES for multiple planning meetings. 


The Foreign Language Department e Ms. Adanna Anyiwo, UMES Pharmacy 


Only a few individuals were lucky Student 
enough to receive this real-world at UMES provided pre-departures | | 
learning experience and life-changing language and culture training to the e Ms. Kimberly Mitchell, UMES 
opportunity. | ask you to reflect upon team. Team members included: Pharmacy Student 
the beautiful land, yet consider the e Dr. Frank Nice, Health and Education Throughout the mission, the team 
poor living conditions of the Haitian for Haiti, Inc. conducted health needs assessments 
people. Commit to Support It, go next ° Mrs. Pat Labuda, Health and at two community clinics, set up 
time, or share with others about this a two pharmacies, provided health 
ye b Education for Haiti, inc. ges 
mission to Haiti — the poorest country care and medications for patients 
in the western hemisphere, perhaps ¢ Dr. Hoai-An Truong, UMES Pharmacy at a community clinic, toured two 
the world. Faculty hospitals, visited an orphanage, and 
On Thursday, May 29 at 6:00 a.m. e Dr. Yen H. Dang, UMES Pharmacy attended class at a nursing school. 
thirteen people with a common Faculty According to some team members, 


this mission is distinctive because 


purpose, often mentioned 

in health professional oaths 
to “aid in the relief in human 
suffering,” departed the U.S. 
Capital for the Haitian Capital, 
Port-au-Prince. All left their 
loved ones, their luxury 
lifestyle, and their “e- and 
i-products” (e.g. iPad, iPhone, 
electronics, etc.) to embark 
on a journey to help the 
Haitian people on a weeklong 
mission trip. 


This Haiti mission was an 
academic-community and 
interprofessional initiative 
among members of the 
University of Maryland 
Eastern Shore (UMES) School 
of Pharmacy and Health 
Professions (Pharmacy 


MARYLANDPHARMACIST.ORG fi 9 


av A 


66 See not just with your eyes, 
but with your heart. Care not just 
with your minds, but with your 


open hands.” 


—A reflection by Hoai-An Truong, PharmD, MPH 


“we immerse ourselves — eat with the 
local hosts and live with the Haitian 
people.” As volunteers we were kindly 
welcomed into the community where 
we were introduced to many people. 
Together, we worshipped in a church 
on the beach, taught in a primary 
School, participated in a talent show 
and dance, and walked along the 
beach with children. It was an amazing 
experience when the children held our 
hands when we walked and gave us 
conch shells as souvenirs, which will 
always remind us about the sounds of 
Haiti — the soul of the Caribbean. 


The mission reinforced to us the true 
meaning of humanity and how all of 
us need the help and support of one 
another. | personally, experienced a 
touching moment as | encountered a 


10 MARYLAND PHARMACIST | ! 


man while walking along 
the path to the clinic. 

He spoke in Creole and 

| spoke in English. He 
walked up to me, shook 
my hand, and placed my 
hand over his heart on 
his bare chest. Humanity 
is the universal language. 
| understood. It was an 
indescribable feeling. | 
imagine that it would be 
hard for any team member 
to deny similar emotions at some 
point during the mission, especially 
when we personally interacted with 
our patients. 


In addition to the humbling, 
rewarding experiences and 
amazing, lifelong memories, 
our lesson beyond the 
academic walls taught us 
new meanings to poverty, 
gratitude, flexibility, patience, 
emotion, attitude, and 
“chikungunya” — perhaps 
the most popular word due 
to a recent epidemic from 
mosquito bites. Fortunately, 
no one caught it and only 
one person felt sick for a 
couple days toward the end 


of the trip. Overall, the team supported 
each other and returned healthy. 


On the first day of the mission, Dr. 
Nice stated, “we know that it will be 
and it is difficult as we experience life 
in a third world country. No matter 
how hard it may be, we come and go 
in a week. Yet, the Haitian people live 
there all their lives.” Upon departure, 
team members wrote their actions to 
help Haitians or commit to support 
sustainability on a “postcard” which 
will be mailed to them 3 months 
post-trip. Let us always be reminded 
the lessons of simplicity, giving-back, 
Or pay-it-forward as we return to our 
lives. 


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MARYLANDPHARMACIST.ORG § 11 


DEFINING 


Leadership is.... 


The sentence seems easy enough to 
define until asked the question. Most 
people would answer they know what 
leadership is when they see it, but 

to put it into words is a little more 
complicated. 


As pharmacists tend to do, you start 
the research. Two styles of leadership, 
three styles of leadership, the five 
types of leaders, the 12 types of 
leaders, and on. The definition starts 
to get more complicated. The question 
Starts to become whether there is 

a right answer, So more research is 
necessary. Move on to what is the 
best way to lead. Some argue that 

it is better to be a transformative 
leader instead of a transactional one. 
Transformative leaders are charismatic 
and focus on team building and goal 
Setting. They look at the big picture 
and lead those on the team through 
personal growth. Transactional leaders 


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me BLO ups tyle: 
informal individuals followers 


are masters at getting the job done 
and keep everyone around them 
motivated by incentives and possibly 
fear. Different jobs need different 
leaders. A busy community pharmacy 
filling 500 prescriptions a day would 
probably wish for a transactional 
leader. A pharmacy association looking 
to grow might want a transformative 
leader. Most situations require a 
mixture of both. Research suggests 
that nurses will continue to perform 
well on the job despite the leadership 
style of the physicians with whom 
they work. This study shows that some 
professions intrinsically create leaders 
within that rise independently of their 
superiors on the job. The definition of 
the effect of leadership may change 
depending on the profession or 
Situation. 


Start to research publications on 
pharmacy leadership, as there must 
be answers to the question there. 
Pharmacy is a complicated profession 
SO maybe it is best to go to those 
who know what it is like in 
the real world. It’s a little 
daunting when those 
in your state who 
will potentially be 
reading this article 
wrote most of the 
books published 
on pharmacy 
leadership. New 
practitioners 
and those new to 
leadership benefit from 
the expertise in our profession 
and are encouraged to visit the 
American Pharmacists Association 


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role 


By: Dixie Leikach, RPh, MBA, FACA = 


literature catalog for excellent 
references on the leadership topic. 


There are many types of leadership, 
many “right” ways to lead, and many 
resources on the topic. The definition 
may be in whom we consider leaders. 
There may be a defining moment in 
when you are considered a leader, or 
it may be more gradual. The call to 
leadership is different for everyone. 
Some people find themselves in a 
position without any notice or training, 
and others may view it as a type of 
career path. The path to be a better 
leader is a continual one we should all 
Strive to increase our education and 
experience to improve. 


Trends and definitions may change, 
and the latest way to be a leader may 
have a different author. Yet, there 

are many things that will not change. 
At some point, you will be called to 
lead in your lifetime. It helps to be 
prepared for this. Membership and 
engagement with your state pharmacy 
association can provide opportunities 
for education and experience that will 
increase your knowledge base on the 
topic of leadership. The unique twist 

is that it will be applicable to your 
personal and professional life and you 
will get to experience it among your 
peers. This experience will include 
other pharmacists who are looking to 
increase their knowledge or are there 
to share their experiences. You have 
to show up to go up, so become a part 
of your profession and not just wait for 
it to come to you. That is what leaders 
do. 


On July 14, 2014, Jeff Sherr, owner of Apple Discount Drugs in Salisbury MD, has been awarded 
with the Health Mart Community Healthcare Excellence Award. This award was presented to 
Jeff for consistently providing care and services that add measurable value to patient health 
care and community wellness. The Health Mart Community Healthcare Excellence Award is a 
national pharmacy award that only 10 pharmacists across the country receive. 


Dr. Cynthia Boyle, PharmD, FAPhA, MPhA Past President, has been 
named interim dean of University of Maryland Eastern Shores’ (UMES) 
School of Pharmacy and Health Professions. Previously, Dr. Boyle has 
served as Professor and Chair of the Department of Pharmacy Practice 
and Administration at UMES since August 2011. She has practiced 

in community, institutions, and consultant settings and is an active 
member of the American Association of Colleges of Pharmacy, serving 
in multiple leadership roles and positions. 


G. Lawrence Hogue, BS Pharm, PD, MPhA Speaker of the House, has been 
promoted to Assistant Dean for Professional Affairs at University of Maryland Eastern 
Shore School of Pharmacy and also remains as an assistant professor of Pharmacy 
Practice at UMES. His career path includes 8 years of experience in institutional 
pharmacy and 30 years of experience in independent community pharmacy practice. 


Angelo C. Voxakis, PD, CEO of EPIC Pharmacies, Inc., will retire at the end of December after 

16 years of service. Angelo has been an independent pharmacy owner since 1989 and has been 
President of EPIC Pharmacies, Inc. since 1999. EPIC was founded in 1982 and is a nationwide network 
of more than 1,000 independently-owned pharmacies. Angelo graduated from the University of 
Maryland School of Pharmacy in 1971. 


Nicole Brandt, PharmD, BCPP CGP FASCP Associate Professor at the 
University of Maryland School of Pharmacy, was elected the 2014-2015 
American Society of Consultant Pharmacists (ASCP) President-Elect. Nicole 
graduated from the University of Maryland School of Pharmacy in 1997 and 
completed a geriatric residency and is board certified in psychiatric and geriatric pharmacy. Nicole 
has been actively involved in ASCP since 2002. 


Magaly Rodriguez de Bittner, PharmD, BCPS, CDE, FAPhA, professor 
and chair of the Department of Pharmacy Practice and Science at the 
University of Maryland School of Pharmacy was named a Maryland Daily 
Record 2014 Innovator of the Year. The Daily Record is a leading business 
and legal news publication and recognizes Marylanders for their 
innovative spirit. Dr. Rodriguez de Bittner was selected for her efforts to 
establish and expand the Maryland P3 Program across the nation. 


Do you have good news to share? 


Send your Member Mention to kelly.fisher@mdpha.com. 
Please enclose a photo if possible. 


MARYLANDPHARMACIST.ORG ff 13 


iii 


Medication reconciliation is the process of documenting a 
patient's complete, accurate medication list at times of transitions 
in care and comparing the list to prior lists to ensure changes are 
addressed. The medication reconciliation process is recognized 
as Critical for patient safety and is most often discussed in the 
context of the hospital setting, during admission, transfer and 
discharge. However, medication reconciliation is equally important 
in other care settings (nursing homes, hospice, ambulatory 

care, Outpatient settings, other) especially at patient transitions 
between these different care settings." 


In one study investigating medication discrepancies conducted 
in an academic hospital, over one-third (35.9%) of patients had 
medication errors on admission and 85% of these were errors 

in medication histories. The authors suggested that prescribers 
and other clinicians should help patients obtain and maintain a 
complete, accurate and understandable medication list. 


Recognition of the need to engage patients and their family and 
Care givers in medication reconciliation was recently the focus of 
a Collaborative project by the three pharmacy schools in Maryland 
and the Delmarva Foundation, National Disparities Coordinating 
Center. The teams included: Dr. Chanel Agness, Dr. Leah Sera, 


14 MARYLAND PHARMACIST | 


Smart Medicine 
Management for 
Older Adults 


By Jennifer Thomas, PharmD 


Roxanne Zaghab, Dr. Regina Atim, and Peter 
Barakat, PharmD Candidate, from the University of 
Maryland; Dr. Regine Beliard, Dr. Jennifer Bailey, Dr. 
Ashley Wensil and Dr. Min Kwon from Notre Dame 
of Maryland University; and Dr. Hoai-An Truong, 

Dr. Lana Saad and Rosemary Botchway from the 
University of Maryland Eastern Shore. The primary 
aim of the team collaborative was the development 
of a medication safety toolkit to include a 
medication reconciliation process applicable to 
patients and caregivers. A secondary aim was to 
develop training videos and slide sets for patient 
care advocates, such as community health 
workers and healthcare professions students, to 
educate patients, their families and caregivers 
about the importance of having knowledge of their 
medications. 


While there are a number of medication 
reconciliation tools with the focus of healthcare 
professionals to complete the medication list, 
there is a paucity of tools that focus on education 
of patients and/or patient health advocates to 
complete medication reconciliation. Two key 
elements were identified early in the development 
of the toolkit by the collaborative team as key to 
successful medication reconciliation: 


Understanding the importance of maintaining 
a current list of medications at all times 


Maintaining a current list of medications is 

the foundation for education to the patient on 
medication management. However, having a 
Current list of medications, available at all times, 

is difficult, especially for those patients that have 
multiple medications, multiple prescribers, multiple 


pharmacies, low health literacy (the majority of patients), and other factors such as reading and/or vision limitations. The 
collaborative team created the Med-Check Passport which is a document analogous to the country of residence Passport. 
just as the traveler must carry their citizen passport to visit another country, the patient must carry their “Med-Check 
Passport” medication list when they visit their healthcare prescribers and pharmacies. 


Understanding that medication changes are significant 


The Med-Check Passport emphasizes the medication changes that occur within the patient's medication list and provides a 
specific column within the table to document the reason for the change. 


Examples of the Med-Check Passport 


Version 1: Used by community health workers and patients; developed by Notre Dame of Maryland University and 
University of Maryland. Show your Med-Check Passport at every medical appointment. 


See Med-Check Passport: http://youtu.be/1LQC9YFO3EAW 

Med-Check Questions 

Questions the community health worker can ask the patient 

If the patient answers YES to ANY question, tell the patient to tell their pharmacist or doctor! 

1. Do you use more than one pharmacy? 

2. Do you have trouble paying for your medications? 

3. For each medication you listed, are there any sections in the green or blue column that you could not fill out? 
4. Have you stopped taking any of your medications on your own without telling your doctor? 

5. Do you have trouble remembering to take any of your medications? 


Directions Completed by: 


MED-CHECK PASSPORT 


Step 1 

Fill out the first 6 
columns with all 
medications you are 
Supposed to take 


Step 2 

Fill out the last 3 
columns every time 
there is a change to 
your medications 


Step 3 

Fill out the first 

6 columns every 
time you start a new 
medication 


Remember 
Include all 
prescription 
medications, 

over the counter 
medications, 
vitamins, minerals 
and special teas. 


“No=N 
“Yes. Reasons = transportation (T), cost (C). told by family or frend to not take medication (Ml, side effects (5), forgets (F). | take it differently than prescribed {P}, | don't think | need 
this medication (D} 


MARYLANDPHARMACIST.ORG fi 15 


Version 2: Used by student pharmacists and patients; developed by University of Maryland Eastern Shore. 


See How to use the Med-Check Passport: 
https://www.youtube.com/watch?v=sVXaL 1DORe0&list=UUVGUqYdfhULoalbP7CMOKwg 


Med-Check Passport 


Bring it to every 
doctor or 


pharmacy visit 


You will write down a list of all the medications Name: 
that you are taking, how you take them, how 
much, and how often. 

{Include the medications you buy over-the-counter, Pharmacy: 
herbals, vitamins, supplements, etc.} 


Telephone number:___ 


Doctor: 
Do you have any allergies (list all)? 
: : Quality improvement, 
\VWe will review them to properly take care of you. ¢. Ceauabiions \DNCC DFC 
Dect | en eet 


Talk to your doctor or pharmacist if you have 
F e ? Developed ia paetacextip by tie Ussversiay of Mary lead Eat Sheete (UMES) Schead of Pharmacy, acd the 
any questions about your medications Prinary Care CosStine of Mimtgemery Coenty This ensticsidl ecss gecgurcd bry th: Debesrva Frandea feu 


Mfodice! Cate (FMC), the Disparities Maticmal Cocediessing Qestcr, undo contract with ihe Concer for 
Maticare & Meuicaid Sewaces (CMS), at agency of thee US Deperteced of Hoth and Human Services The 
cuMens presente diy eed noeewariby ceflert CMS peliey LOGO -MOLDIOC 0711 14-558 


Example of the electronic Med-Check Passport: www.medcheckpassport.com 


‘) Med-Check Passport x 
/ 


€ > C [5 www.medcheckpassport.com/startpassport.php a iv : > x 
MedCheck 


Create New Passport 


Name 

Email (to save your passport, you must provide your email addresss) 
Telephone Number 

Pharmacy 

Doctor: 


Do you have any allergies (list ail)? 


Load Old Passport 


EK ee 
| Start Passport | 
. www.medcheckpassport.com/loadpassport.php 


ee Fo 8 8) aaa 


16 MM MARYLAND PHARMACIST | 


Example Disease State Module: Heart Failure MedCheck Symptoms Check 
This tool can help you keep track of heart failure symptoms. Use this tool to understand what to do if your 


heart failure symptoms get worse. 


The toolkit is a package of educational 
materials with training videos, paper tools, 
and an electronic application to specifically 
assist patients and non-professionals 

that work with patients to obtain and 
maintain their medication list. Specific 
toolkit components include: the Med-Check 
Passport, medication list (2 versions) and 
associated video instructions; the Smart 
Medicine Safety Checklist with video, a 
Screening tool to identify potential medication 
problems; and the Heart Failure Symptoms 
Check with instructional videos, a tool to 
provide a disease state specific medication 
and symptoms review, along with suggested 
actions for the patient to take. The complete 
Med-Check Toolkit may be accessed at the 
Delmarva Foundation website.s (Note: The 
toolkit may also be posted on the Maryland 
Pharmacists Association website and on 
the individual School of Pharmacy web 
resources.) 


As American Pharmacists Month is fast 
approaching there is an opportunity 

for pharmacists and other healthcare 
professionals to avail themselves of the Med- 
Check Toolkit as valuable resources to engage 
with their patients to improve medication 
reconciliation. To obtain the most value from 
the Med-Check Toolkit the reader may wish to 
review all the paper tools and videos?. 


1. Agency for Healthcare Research and Quality Patient 
Safety Primer: Medication Reconciliation. http://psnet. 
ahrq.gov/primer.aspx?primerID=1 Accessed September 
4, 2014. 


2. Results of the Medications At Transitions and Clinical 
Handoffs (MATCH) Study: An Analysis of Medication 
Reconciliation Errors and Risk Factors at Hospital 
Admission Gleason KM, McDaniel MR, Feinglass J, et al. J 
Gen Int Med 2010;25:441-7. 


3, Delmarva Foundation for Medical Care. July 2014, “The 
Med-Check Toolkit: Smart Medicine Management for 
Older Adults,” Columbia, Maryland. 


Medication Safety http://www.dcgio.org/providers/ 
pharmacymedication-safety/medication-safety 


Chart 1 - Heart Failure MedCheck — Symptoms Check 
Patient name: 


« No shortness of breath 
« No increase in swelling 
+ No weight change 

« Normal activity 


Continue taking medication as 
directed 


@| 


SYMPTOMS YELLOW ZONE 


+ Increased shortness of breath 
+ Increased swelling 
« Weight change by 2 pounds ina CAUTION 
day + Call your doctor 
+ Weight change by 5 pounds in a 
week 
+ Decreased activity 


+ Symptoms in the yellow zone are 
not better after calling your doctor 

+ Shortness of breath that won’t go | |- Get help from the doctor now 
away OR 

+ Chest pain that won’t go away + Call 9-1-1 for help 

+ Dizziness or fainting 


Chart 2 - Heart Failure MedCheck — Symptoms Check 
Patient name: 
Check for the following symptoms daily and write in your zone “ED 


GREEN <7 YELLOW ee 
MONDAY TUESDAY WEDNESDAY | THURSDAY FRIDAY es Fad 
4/4/2014 


- sa on 


a ey 
CALL 
ACTION CONTINUE 
BOCTOR 


A 1 ene es reper ye Dames Funct fer Msi Cae JOFAC) se pris persona Coordinating Contr, unde catract mith ie Centers fr Masicare & Mesicis 
9 fp gabrpeemet inn | DME : 


MARYLANDPHARMACIST.ORG i 17 


Wa leader. 

© an educator. 

5 a trusted advisor. 
a 


a counselor. 


- ALL ABOUT 


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Charged with balancing the demands of 
delivering excellent patient care with top 
operational performance, you understand the 
need for quality solutions and integration at 


every step along the way. So do we. 


That’s why we're combining our full suite of pharmaceutical 
management offerings to deliver solutions and insight across the 
continuum of care. Now is the time for you to concentrate on 
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Cardinal Health is eager to discuss your business needs. 


For more information contact one of our Pharmacy 
Business Consultants. Visit cardinalhealth.com/allaboutyou 


CardinalHealth 


Essential to care™ 


© 2013 Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or 
registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Lit. No. 1RI12495 (09/2013) 


CONTINUING EDUCATION 


Mohamed T. Sarg, Pharm.D., BCPS, PGY1 Pharmacy Practice Resident 
Lauren Hynicka, Pharm.D., BCPS, Assistant Professor 
University of Maryland School of Pharmacy, Baltimore 


New guidelines tor~ 
cholesterol management: 


What has changed? 


Cholesterol and triglycerides are the major lipids circulating in the human body. They are transported 
as complexes of lipids and proteins known as lipoproteins. The three major classes of lipoproteins are 
low-density lipoproteins (LDL), high-density lipoproteins (HDL), and very-low-density lipoproteins (VLDL). 
Hyperlipidemia is a group of disorders characterized by an excess of serum cholesterol, especially low- 
density lipoproteins and/or excess triglycerides. It Is classified as either primary hyperlipidemia (genetic 
or familial) or secondary hyperlipidemia which can be caused by age, diabetes mellitus, hypothyroidism, 
Cushing's syndrome, chronic kidney disease, or cholestatic disorders. Several drug classes have 

been linked to secondary hyperlipidemia, including: HIV protease inhibitors, atypical antipsychotics, 
corticosteroids, isotretinoin, beta-blockers, thiazide diuretics, azole antifungals, cyclosporine, tacrolimus 
and some types of oral contraceptives.’ Several studies have established a definitive association 
between elevated levels of LDL cholesterol and the risk of cardiovascular disease. | 


Panel-lll guidelines. 


In 1988, the National Heart, Lung, 

and Blood Institute (NHLBI) began 
publishing the National Cholesterol! 
Education Program - Adult Treatment 
Panel (NCEP-ATP) guidelines for 
hyperlipidemia management. Since 

its inception ATP-| has been updated 
once in 1993 (ATP-Il) and again in 2002 
(ATP-Ill).2 However, in response to 

the 2011 Institute of Medicine’s report 


Learning Objectives: After reading this article, the learner will be able to: 
1. Identify the 5 main differences between the 2013 ACC/AHA lipid guidelines and 2002 Adult Treatment 


2. Recognize the four patient population groups that would benefit from HMG CoA reductase inhibitor 
(statin) therapy based on the new ACC/AHA treatment guidelines. 


3 Recommend a statin therapy based on a patient's risk level. 


Key Words: Hyperlipidemia, statins, cholesterol, LDL, ATP Ill, HMG CoA reductase inhibitors 


on the development of trustworthy 
guidelines, the NHLBI Advisory Council 
recommended that the NHLBI focus 
specifically on reviewing the highest- 
quality evidence and partner with 
other organizations. Accordingly, 

in June 2013 the NHLBI initiated 
collaboration with the American 
College of Cardiology (ACC) and the 
American Heart Association (AHA) 


to complete and publish these 
guidelines. 


The 2013 ACC/AHA lipid guidelines 
provide a new approach to the 
treatment of hyperlipidemia, which 
deviates from the ATP-Ill guidelines 
in a number of ways.° The purpose 
of this article is to highlight the key 
differences between the current and 


MARYLANDPHARMACIST.ORG ff 19 


previous guidelines. These differences 
include treatment population, goals 

of therapy, selection of lipid lowering 
medications, a new risk calculator and 
Safety and monitoring of regimen. 


identification of Treatment 
Population 


The first difference is the patient 
population that is likely to benefit from 
Statin therapy. The 2013 ACC/AHA 

lipid guidelines identify four groups 
whom are likely to benefit from statin 
therapy. These four patient groups 
include the following (See Table 1): 


e History of arteriosclerotic 
cardiovascular disease (ASCVD) 


e LDL-cholesterol > 190 mg/dl 


e Between 40 and 75 years of age with 
a history of diabetes 


eBetween 40 and 75 years of age and 
a 10-year ASCVD Risk > 7.5% 


¢ Coronary heart Disease patients (CDH) 


e Acute Coronary Syndrome 

¢ Myocardial Infarction 

¢ Stable or unstable angina 

e Revascularization procedures 
¢ Coronary angiography 
¢ Coronary artery surgery 


¢ Other atherosclerotic diseases 


e Peripheral vascular Disease 
¢ Abdominal aortic aneurysm 
¢ Carotid artery disease 
¢ CHD risk equivalent 

¢ Diabetes mellitus (type | or II) 


e 2+ risk factors 


¢ Cigarette smoking 


antihypertensive medication) 


¢ 20% Calculated 10 year CHD Risk 


20 §§ MARYLAND PHARMACIST | 


¢ Hypertension (BP >140/90 mmHg or on 


¢ Low HDL cholesterol (<40 mg/dL) 


¢ Family history of premature CHD (CHD in 
male first-degree relative <55 years; CHD 
in female first-degree relative <65 years) 


Therapeutic Goals 


The second key difference is the 

goals of hyperlipidemia therapy (Table 
2). IN previous guidelines, therapy 

was targeted towards a specific 

LDL and non-HDL goal based on the 
presence of comorbidities. However, 
the advisory panel for the ACC/AHA 
recommended that the goal of therapy 
Should be cardiovascular event 
reduction. The best way to accomplish 
this is for patients identified as statin 
eligible, as stated in table 2, to be 

on the maximum tolerated statin 
intensity regardless of their LDL level. 
The guidelines discuss specifically 
using high and moderate intensity 
statins to accomplish this goal. More 
information about statin intensity will 
be provided later in the article. 


Selection of Lipid-lowering 
medications 


In the ATP-IIl guidelines, selection of 
the lipid lowering agent depended on 
several factors. The first consideration 


Table 1: Methods and Outcomes . 
ATP-III' 2013 ACC/AHA4 


@ Clinical Atherosclerotic Cardiovascular Disease 


(ASCVD) 
e Acute Coronary Syndrome 
¢ Myocardial Infarction 
e Stable or Unstable Angina 


e Revascularization Procedures 


in Origin 
e LDL > 190 mg/dL 


years 


e Stroke or Transient Ischemic Attack 


e Peripheral Arterial Disease Atherosclerotic 


¢ Diabetes mellitus (type | or Il) AND Age 40-75 


¢ 10-year ASCVD Risk > 7.5% AND Age 40-75 years 


was the patient's lipoprotein profile 
and whether there were additional 
lipid abnormalities beyond an elevated 
LDL. Second, the magnitude of change 
needed to reach the goal of therapy 
was considered. Finally, concomitant 
drug therapies that may increase 

the risk of side effects and/or the 
presence of other medical disorders 
that may influence drug metabolism 
were considered.* Statins are usually 
the drug of choice due to their 
effectiveness in lowering LDL and 
tolerability by most patients. However, 
the ATP-IIl guidelines gave prescribers 
the option to initiate patients on 
alternative lipid-lowering agents 

(Table 3). If the patient did not have an 
adequate response, prescribers then 
could either change therapy to a statin 
or use the statin in combination with a 
non-statin to achieve target LDL goals. 


On the other hand, the new ACC/AHA 
guidelines focus on optimizing statin 
based therapy for cardiovascular 
event risk reduction. The new 
guidelines classify 
Statins based on their 
lipid lowering intensity 
(Table 4). Patients receive 
either moderate- or 
high-dose statin therapy 
depending on which of 
one of the four “statin 
benefit groups” they 

fit into. High-intensity 
options lower the LDL by 
approximately 50% and 
include: 20 or 40 mg of 
rosuvastatin daily or 40 
or 80 mg of atorvastatin 
daily. Patients who 
should receive a high- 
intensity statin include 
the following: patients 
with clinical ASCVD, LDL 
>190, and patients with 
diabetes AND estimated 
10-year ASCVD risk 
>7.5%. In general it is 
recommended that 
patient start on the 
highest dose and titrate 
down if they develop 
adverse events. According 
to the new guidelines, 
moderate-intensity 
therapy is acceptable for 


patients who are 40 - 75 years of age 
with diabetes AND have an estimated 
10-year ASCVD risk <7.5%, patients 
with an LDL of 70 mg/dL - 189 mg/ 
dL, patients who have no evidence 

of clinical ASCVD, and patients with a 
10-year risk of ASCVD that is less than 
7.5% Or patients who are 75 years of 
age or older with ASCVD. 


Another major change in the new 
hyperlipidemia guideline is the 
downgrading of non-statin treatment 
options. Per the ACC/AHA expert 
panel, “Non-statin therapies do 

not provide acceptable ASCVD risk 
reduction benefits compared to their 
potential for adverse effects in the 
routine prevention of ASCVD".® This 
recommendation is anticipated to 
eventually lead to a reduction in the 
number of prescriptions for ezetimibe, 
ezetimibe-containing products, bile 
acid sequestrants, fibrates, niacin, 
niacin-containing products and 
omega-s3 fatty acids.° 


New Risk Calculator 


The ACC/AHA guidelines now utilize 
a pooled cohort risk assessment 


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instead of the Framingham Risk 
Calculator, to estimate 10-year and 
lifetime risks for a patient to develop 
ASCVD (defined as coronary death 
or nonfatal myocardial infarction, 

or fatal or nonfatal stroke). The 
information required to estimate 
ASCVD risk includes age, Sex, race, 
total cholesterol, HDL cholesterol, 
systolic blood pressure, blood 
pressure lowering medication use, 
diabetes status, and smoking Status. 
This tool is available through www. 
my.americanheart.org either as a 
mobile application or a web-based 
calculator.® 


AS a result of new recommendations 
in the 2013 ACC/AHA hyperlipidemia 
guidelines, the number of adults 
receiving statin therapy in the United 
Sates is expected to increase from 
43.2 million to 56.0 million. Most of this 
increase (10.4 million of 12.8 million) 
would occur among adults without 

a history of cardiovascular disease. 
Among adults between the ages of 60 
and 75 years without cardiovascular 
disease who are not receiving statin 
therapy, the percentage of those who 


would be eligible for such treatment 
would increase from 30.4% to 87.4% 
among men and from 21.2% to 53.6% 
among women.’® 


Statin Safety & Monitoring 


Another difference between the 
guidelines is the recommendations 
for monitoring statin therapy. Both 
guidelines agree that the following 
items should be assessed regularly: 
adherence to medication and lifestyle 
modifications, therapeutic response 
to statin therapy, and safety. Refer 

to Table 5 for a comparison of 
recommended monitoring. 


Liver Function Tests 


The 2013 ACC/AHA guidelines 
recommend against routine 
monitoring of liver function tests 
(LFTS) but recommend that baseline 
LFTs be obtained in all patients 
prior to statin therapy initiation. 

The guidelines state that based on 
recent randomized clinical trials 

the incidence of transaminitis in 
individuals on high-dose statin 
therapy is less than 1.5% Over 5 years. 


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Treatment LDL goals based on lipid serum 
levels and risk stratification 


¢ CHD and CHD Risk Equivalent <100 
mg/dL 


¢ Framingham 10 year risk >20% <100 
mg/dL 


e Multiple (2+) Risk Factorsa <130 mg/dL 
¢ 0-1 Risk Factor <160 mg/dL 


Elevation in LFTs associated with low- 
or moderate-intensity statin therapy 
occurred at rates similar to those seen 
with placebo or no statin treatment 
controls. 


Creatinine Kinase 


The 2013 ACC/AHA guidelines 
recommend against routine CK 
monitoring. In contrast to the ATP- 
Il guidelines, which recommend 
evaluation of CK levels prior to 
therapy initiation and again if a 
patient presents with symptoms 
of muscle pain, the new guidelines 
recommend evaluating CK initially 
only if the patient is at high risk for 
developing adverse muscle events. 


Table 2: Goals of hyperlipidemia therapy 


ATP-III" 2013 ACC/AHA‘ 


e Cardiovascular events risk reduction 


e Treating to a target LDL goal is not 


e Use maximum tolerated statin intensive 


a Heavy smoker, uncontrolled hypertension, strong family history of premature CHD, or very low HDL cholesterol 


recommended 


therapy 


These include patients with personal 
or family history of statin intolerance 
or muscle disease, have clinical signs 
and symptoms of muscle disease, or 
are on concomitant drug therapy that 
might increase the risk for myopathy. 
Some examples of medications which 
can increase the risk for myopathy 
include fibrates such as gemfibrozil 
and niacin. The guidelines provide 

an algorithm to avoid unnecessary 
discontinuation of statin therapy due 
to muscle pain complains (Figure 1).° 


Diabetes 


There is moderate evidence that 
patients on statin therapy are at risk 
of developing new onset of diabetes 


mellitus (Number needed to harm 
[NNH] = 100 in primary prevention and 
500-1000 in secondary prevention).? 
The new guidelines recommend that 
patients who develop diabetes while 
on statin therapy should adhere to a 
heart healthy diet, engage in physical 
activity, achieve and maintain a 
healthy body weight, cease tobacco 
use and to continue statin therapy. 


Triglycerides (TG) 


The ACC/AHA could not find evidence 
that starting triglyceride-lowering 
medication therapy for TG levels of 
500-1000 mg/dL lowered the risk 

of hyperlipidemic pancreatitis. The 
guidelines recommend evaluating 
and addressing secondary causes of 
elevated TG levels and implementing 
diet and lifestyle modifications as first 
line therapy for these patients rather 
than starting them on triglyceride 
lowering medication. The ACC/AHA 
guidelines now recommend that 
therapies targeted at TG be initiated 
when the value is > 1000 mg/dl. 
Table 6 compares the triglyceride 
management recommendations for 
each of the guidelines. 


Table 3: Recommended lipid-lowering agents 
ATP-III' 2013 ACC/AHA?® 


¢ HMG CoA reductase inhibitors (statins) 


¢ HMG CoA reductase inhibitors (statins) 


e Atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin 


& simvastatin 


¢ Bile acid sequestrants 


¢ Cholestyramine, colestipol & colesevelam 


e Nicotinic acid derivatives 
e Niacin extended release 

e Fibric acid derivatives (fibrates) 
¢ Gemfibrozil, fenofibrate 

¢ Antilipemic Agent 
¢ Ezetimibe 


¢ Omega-3 fatty acids 


22 M)} MARYLAND PHARMACIST | 


& simvastatin 


e Atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin 


e Adjunct therapy (statin + nonstatin) is not recommended due to 
lack of supporting evidence 


Table 4: ACC/AHA statin classification® 
A High-Intensity Statin Therapy Moderate-Intensity Statin Therapy Low-Intensity Statin Therapy 


Daily dose lowers LDL by approximately Daily dose lowers LDL by approximately 30% | Daily dose lowers LDL by 
>50% to <50% <30% 


Atorvastatin (40)-80 mg QD Atorvastatin 10 (20) mg QD Simvastatin 10 mg QD 
Rosuvastatin 20 (40) mg QD Rosuvastatin (5) 10 mg QD Pravastatin 10-20 mg QD 
Simvastatin 20—40 mg QD Lovastatin 20 mg 
Pravastatin 40 (80) mg QD Fluvastatin 20-40 mg BID 
Lovastatin 40 mg QD 
Fluvastatin XL 80 mg QD 
Fluvastatin 40 mg BID 
Pitavastatin 2-4 mg QD 


Table 5: Statin monitoring 
Oe SS OS ATP-IIr 2013 ACC/AHA® 


Fasting Lipid panel Evaluate initially, approximately 4-12 Evaluate initially, approximately 4-12 
weeks after starting, then annually or more | weeks after starting, then annually or more 
frequently if indicated. frequently if indicated. 


Pitavastatin 1 mg QD 


Liver function test (AST & ALT) Evaluate initially, approximately 12 weeks 
after starting, then annually or more 


frequently if indicated. 


Evaluate initially, and then only if patient 
is developing symptoms suggesting 
hepatotoxicity. 


Muscle soreness, tenderness or pain e Evaluate muscle symptoms and CK initially. | ¢ Evaluate CK initially if patient believed to 
be at increased risk for adverse muscle 


events. 


Creatinine Kinase (CK) e Evaluate muscle symptoms at each follow- 


up visit. 


¢ CK should not be routinely measured in 


¢ Obtain a CK when persons have muscle Soa ie <. 
individuals receiving statin therapy. 


soreness, tenderness, or pain. 
e If patient present with muscle weakness 
follow the algorithm (Figure 1). 


Table 6: Triglyceride management 
ATP-III' 2013 ACC/AHA?® 


Borderline High Triglycerides (150-199 mg/dL): Borderline High Triglycerides (150-999 mg/dL): 


¢ Implement diet and lifestyle modifications e Implement diet and lifestyle modifications 


¢ Body weight control ¢ Body weight control 


e Regular physical activity e Regular physical activity 


e Smoking cessation e Smoking cessation 


e Restriction of alcohol use e Restriction of alcohol use 


) ¢ Avoid high carbohydrate intakes (>60% of calories) 


e Avoid high carbohydrate intakes (>60% of calories 
High Triglycerides (200-499 mg/dL): 


¢ First line: Implement diet and lifestyle modifications 


e Second line: Use Statin/Niacin/Fibrates 
Very High Triglycerides (2500 mg/dL) 


¢ First line: Triglyceride-lowering drugs (fibrate or nicotinic acid) 


Very High Triglycerides (21000 mg/dL) 


e Add Triglyceride-lowering drugs (fibrate or nicotinic acid) in 
addition to statin 


e Second line: Implement diet and lifestyle modifications 
¢ Implement diet and lifestyle modifications 


MARYLANDPHARMACIST.ORG 23 


What is her risk status? (http://my.americanheart. 
org/professional/StatementsGuidelines/Prevention- 
Guidelines_UCM_457698_SubHomePage./sp) 


Sidebar: Determining Statin Intensity 


Mrs. Smith is a 70 year old white woman with hypertension, who presents in your Pharmacotherapy Clinic. She 
takes the following medications: Aspirin 81 mg PO daily, Lisinopril 20 mg PO daily and hydrochlorothiazide 25 mg 

PO daily. She denies use of tobacco products. You also have the following information available from her clinic 

visit. Her systolic blood pressure in clinic today is 120 mmHg. Her last cholesterol panel was check approximately 3 
months ago and indicates a total cholesterol of 180 mg/dl and an HDL of 43 mg/dl. She tells you she has never taken 
medication for high cholesterol. 


QUESTION 1 


shoe 
ied 
CH. 
Criss 


If you were able to navigate successfully to the web 
page and download the risk calculator spreadsheet, you 
found that her risk status was 11.3. Clearly Mrs. Smith 


requires treatment. 
QUESTION 2 


Which of the following would be the best choice of 


medication therapy to initiate? 


a. Atorvastatin 40 mg because she has an indication for 
moderate to high-intensity statin therapy 


b. Pravastatin 20 mg because she doesn’t have any risk 


factors 


c. Fluvastatin 20 mg because she’s at low risk 
d. Pitavastatin 1 mg because it’s the cheapest 


Summary 


In conclusion, the new 2013 ACC/ 
AHA hyperlipidemia guidelines 

have made several key changes 

in the recommendations for 
treating hyperlipidemia. It is now 
recommended that a cardiovascular 
risk calculator be used as an initial 
assessment to determine whether 
the patient is a candidate for statin 


Having read the case carefully you would know that 


QUESTION 3 


“a” is the correct response because she has an LDL 
between 70 mg/dl and 189 mg/dl with no diabetes and 
a 10-year ASCVD risk = 7.5% and should be treated with 
moderate to high-intensity statin therapy. 


She agrees to start therapy, however 8 weeks later she 
presents back in your clinic/store and states “| want my 
money back. | hurt all OVER and this medicine is the 


only new thing I’ve done. This is awful stuff.” What is 
your correct course of action and why? 


a. Give her back her money because she’s clearly 


discontented with her therapy 
b. Hold the medication and restart at a lower dose when 


symptoms have resolved 


c. Stop the drug and tell her to limit fried foods 


d. Tell her to try acetaminophen for the muscle aches 
because she must continue therapy 


The correct answer is “b.” The patient is complaining 


of mild to moderate symptoms that have developed 


during statin therapy. Based on the muscle weakness 
algorithm it would be appropriate to discontinue the 
medication at this time, monitor for resolution of 


symptoms, and restart the medication at a lower dose. 


therapy. Four groups were found by 
the supporting literature to benefit 
the most from statin therapy. Once 

a patient is a candidate for statin 
therapy, it is no longer recommended 
to titrate therapy to a specific LDL 
goal. On the contrary he/she should 
be on the maximum tolerable 

Statin intensity to ensure maximum 
Cardiovascular risk reduction. It is no 


longer recommended to utilize other 
non-statin therapy as a monotherapy 
Or concurrently with statins due to 
lack of Supporting evidence. Even 
though the new guidelines are based 
on the currently available supporting 
evidence, more studies are needed to 
further evaluate the effectiveness of 
these new guidelines. 


REFERENCES 


1 


N 


National Cholesterol Education Panel. Third report of the National Cholesterol Education Pro- 
gram (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in 
Adults (Adult Treatment Panel Ill) final report. Circulation 2002;106:3143-3421 


Talwalkar P Sreenivas C, Gulati A, Baxi H Journey in guidelines for lipid management: From 
adult treatment panel (ATP)-I to ATP-IIl and what to expect In ATP-IV. Indian J Endocrinol Metab. 
2013 Jul} 17(4):628-35 


Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice 
Guidelines. Clinical Practice Guidelines We Can Trust. Wash ngton, DC: National Academies 
Press; 2011 


Grundy SM, Cleeman J!, Merz CN et al. Implications of recent Clinical trials for the National Cho- 
lesterol Education Program Adult Treatment Panel! |I! guidelines. Circulation 2004;110:227-39 


24 MH MARYLAND PHARMACIST | 


Stone NJ, Robinson J, Lichtenstein A, et al. 2013 ACC/AHA Guideline on the Treatment of Blood 
Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: 4 Report of the American 
College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll 
Cardiol. 2013 Nov 7. pii: SO735-1097(13)06028-2. doi: 10.1016/j.jacc.2013.11.002. 


American Heart Association. 2013 Prevention Guidelines Too S; CV Risk Calculator. Available at 
http://my.americanheart.org/professional/StatementsGuidelines/Prevention-Guidelines_ UCM 
_457698_SubHomePage.jsp. Accessed August 16, 2014 


Ginsberg HN. The 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol: Questions, 


Questions, Questions. Circ Res. 2014 Feb 28;114(5):761-4. 


Pencina M, Navar-Boggan A, D'Agostino RB Sret al. Application of New Cholesterol Guidelines 
to a Population-Based Sample. N Engl J Med. 2014 Mar 19. 


American Diabetes A. Standards of medical care in diabetes--2013. Diabetes Care 2013;36 
Suppl 1:S11-66 


Figure 1: Muscle weakness algorithm 


Unexplained severe 
muscle symptom or 
fatigue develop during 
statin therapy 


Discontinue 
Statin 


Establish a casual relationship 
between the statin and muscle 
symptom: Give patient a the 
original or lower dose of the 
same statin 


Discontinue statin 
until symptoms 
resolve 


Obtain history of prior or 
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CONTINUING EDUCATION QUIZ 


PharmCon is accredited by the 

Accreditation Council for Pharmacy ae 
Education as a provider of continuing @ 
pharmacy education. A continuing 


education credit will be awarded within 
Six to eight weeks. 


Program Release Date: 9/30/2014 
Program Expiration Date: 9/30/2017 


This program provides for 1.0 contact hour (0.1) of 
continuing education credit. Universal Activity Number 
(UAN) 0798-9999-14-154-H01-P 


The authors have no financial disclosures to report 


This program is Knowledge Based — acquiring factual 
knowledge that is based on evidence as accepted in the 
literature by the health care professionals. 


Directions for taking this issue’s quiz: 


This issue’s quiz on New guidelines for cholesterol 
management: What has changed? can be found online 
at www.PharmCon.com. 


(1) Click on “Obtain Your Statement of CE Credits for the 
first time. 


(2) Scroll down to Homestudy/OnDemand CE Credits 
and select the Quiz you want to take. 


(3) Log in using your username (your email address) and 
Password MPHA123 (case sensitive). Please change 
your password after logging in to protect your privacy. 


(4) Click the Test link to take the quiz. 


Note: |f this is not the first time you are signing in, just 
scroll down to Homestudy/OnDemand CE Credits and 
select the quiz you want to take. 


MARYLANDPHARMACIST.ORG {ff 25 


HiD 


Helping You Care For Your Community 


26 MM MARYLAND PHARMACIST | 


EXECUTIVE DIRECTOR'S 
MESSAGE 


Thank you to those 
members who reach 
out to the office 

to ask questions, 
look for resources, 
provide information 
or volunteer their 
time in various 
ways. We would not 
be here without you 
and we appreciate 
your support and 
attention. 


eT ae 


Autumn is here and everything is 
Starting to move again. It has been 

an exciting Summer at MPhA and 

we continue to be amazed by the 
wonderful members that we have who 
are dedicated to the mission of the 
Association. 


This is also the time to renew 
your dues for MPhA! | would like to 
encourage you to cross this off of your 
“To Do" list Sooner rather than later. 
Dues are due by 12/31/2014 for the 
2015 year. If you have any problems 

or questions while renewing then | 
encourage you to call the office at 
410.727.0746 or email Shawn Collins at 
shawn.collins@mdpha.com. Shawn is 
our Membership Benefits Coordinator 
and she is here to help you with your 
renewals and any other questions you 
have about your MPhA membership! 


We recognize that engaged members 
renew so we also added a committee 
Sign-up sheet with your membership 
renewal form. Please be sure to 

take a look at all of the various 
committee opportunities that MPhA 
has to offer you! A description of all 
the Committees is also listed on our 
website. Committees are a great way 
to get involved in the daily workings 
of MPhA and to see exactly what it is 
that the Association does and what 

it has to offer you. The more you get 
involved, the more you will feel that 
MPhA is a part of your professional 
life. Remember that the Board of 
Trustee meetings are open to all 
members each month. There is a 
closed session at the end of every 
monthly board meeting to handle any 
confidential business. We encourage 
you to attend one of the remaining 
board meetings this year. The dates 
are October 29, November 20, and 
December 18. Please just let us Know 
you are attending by RSVPing online. 


What happened to the extra 
contributions that you used to make 


on the dues renewal form? These 
donations have decreased significantly 
over the years and we recognize that 
many of our newer members are not 
familiar with their purposes. Therefore, 
the office will be developing more 
information about the programs that 
we raise money for and soliciting for 
these separately. Please be on the 
lookout for future mailings about our 
supplemental opportunities to support 
MPhA programs, such as scholarships, 
survival funds, and of course our 
MPhA Foundation. 


Mid-Year 2015 will be here soon and 
we have a great line up of Speakers 
and programs. Make plans to attend 
on February 15, 2015 and be on the 
lookout for more information. The 
Monday Message is the best way to be 
sure to know what is happening with 
the Association. All members should 
receive an email from MPhA every 
Monday! If you are not receiving this 
important publication, please email 
Kelly Fisher at kelly.fisher@mdpha.com 
and ask to be added to the list. Be sure 
to “Like” us on Facebook, “Follow” us 
on Twitter, and “Connect” with us on 
Linkedin. Social media and electronic 
newsletters are the most efficient 
ways for us to get quick information 

to our members. We are also just a 
phone call away! Thank you to those 
members who reach out to the office 
to ask questions, look for resources, 
provide information or volunteer their 
time in various ways. We would not be 
here without you and we appreciate 
your support and attention. 


Sincerely, 


oe 


Dixie Leikach, RPh, MBA, FACA 
Interim Executive Director 
Dixie.Leikach@mdpha.com 


MARYLANDPHARMACIST.ORG if 27 


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2 BX MARYLAND PHARMACIST | SUMMER 2¢ 


Dear Members, 


| would like to take this time to Summarize 
our 2013-14 accomplishments that | 
presented at the House of Delegates 
during our 132nd Annual Convention. As 
usual, the Convention was a wonderful 
time with great programs and speakers. A 
big thank you goes out to the MPhA Staff 
and the Convention Committee for all 
their hard work. 


Membership has continued to remain 
Stable with a slight growth in new 
practitioners. Deanna Tran and Ashley 
Moody, co-chairs of the New Practitioner 
Network, along with the rest of the 

NPN, has worked tirelessly to create 

fun activities and events for those that 
have graduated in the last five years to 
be involved in the Association. We are 
seeing the fruits of their labor in our 
membership numbers and know this will 
continue to grow. We always welcome 
new practitioners and pharmacists and 
encourage you to make the effort to 
encourage others you know or work with 
to join the Association! 


The Association continues to be 

fiscally strong. The Kelly Fund that 

was established prior to our move to 
Montgomery Park continues to provide 
the bulk of our budget income. We 

are grateful for our relationship and 
investment advice from Edelman & 
Associates. Our Budget and Finance 
Committee, as well as Treasurer, Matthew 
Shimoda, should be commended for their 
job well done. 


| have enjoyed working with our current 
Board of Trustees and look forward 

to continuing our work with the new 
2014-15 Board of Trustees. Brian Hose will 
remain your Chairman of the Board and 
| will continue as President until the new 
officers are installed in February 2015. 
Dixie Leikach, who would have been 
installed as President at Convention, will 
continue in her role as Interim Executive 
Director until a replacement is found. 


Our committee structure is continually 
evolving and we encourage you 

to join a committee that you find 
interesting. We are hoping to continue 
to develop our committees to be 

the workforce of the Association's 
activities and to also provide training 
for our future leadership. If you have 
any questions about our committees, 

| encourage you to contact me. 


Many exciting events are coming up! Our 
Mid-Year Meeting will be held in February 
2015, with a finalized date coming soon! 
We will present our first Technician of the 
Year award during this meeting so look 
for the nomination form in the fall. 


Currently, the Association's biggest 
projects are the Executive Director search 
and the purchase of our new building 
space. There will be big announcements 
over the up-coming months so please 
read our Monday Message and Maryland 
Pharmacist for all of the latest news 

and information! 


Sincerely, 


O puisticate,-(D-teon9 


Christine Lee-Wilson, PharmD 
President 


& Se 


MARYLAND PHARMACIST 


a 
ge * —-_ * 
=~ Sat 
By Pty 
FEATURES | 
A 2014 Graduating Classes 


Recognizing Excellence 


Script Your Future Baltimore 


Calling All Authors! 


132nd Annual Convention 


On the Hill for Rximpact Day 


DEPARTMENTS 


Zz 

9 
12 
13 
19 
25 
2, 


President's Pad 
Welcome New Members 
Corporate Sponsors 
Member Mentions 
Continuing Education 
CE Quiz 


Executive Director's 
Message 


SUMMER 2014 


ADVERTISERS INDEX 


8 


12 
28 


Cardinal Health 
Foundation 


Buy-Sell-A-Pharmacy 


University of Maryland 
Eastern Shore 


MPhA OFFICERS 2014-2015 
Brian Hose, PharmD, Chairman of the Board 
Christine Lee-Wilson, PharmD, President 

Hoai-An Truong, PharmD, Vice President 

Matthew Shimoda, PharmD, Treasurer 

Lynette Bradley-Baker, PhD, RPh, Honorary President 


HOUSE OFFICERS 
G. Lawrence Hogue, BSPharm, PD, Speaker 
Chris Charles, PharmD, Vice Speaker 


MPhA TRUSTEES 

Nicole Culhane, PharmD, 2016 

Kristen Fink, PharmD, BCPS, CDE, 2015 

Mark Lapouraille, RPh, 2016 

Cherokee Layson-Wolf, PharmD, CGP, BCACP., FAPhA, 2017 

Ashley Moody, PharmD, 2017 

Wayne VanWie, RPh, 2015 

Nghia Nguyen, ASP Student President, Notre Dame of 
Maryland University 


EX-OFFICIO MEMBERS 
Dennis Killian, PharmD, PhD, Interim Dean 

University of Maryland Eastern Shore School of Pharmacy 
Natalie Eddington, PhD, Dean 

University of Maryland School of Pharmacy 
Anne Lin, PharmD, Dean 

Notre Dame of Maryland University School of Pharmacy 
David Jones, RPh, FASCP, MD-ASCP Representative 
Brian Grover, PharmD, MSHP Representative 


CONTRIBUTORS 
Kelly Fisher, Maryland Pharmacist Editor 
Marketing Coordinator 


PEER REVIEWERS 

Chris Charles, PharmD 

Caitlin Corker-Relph, MA, PharmD Candidate, 2017 
G. Lawrence Hogue, BSPharm, PD 

Edward Knapp, PharmD 

Frank Nice, RPh, DPA, CPhP 

Cynthia Thompson, PharmD 


Special thanks to the following contributors: 
Dixie Leikach, RPh, MBA, FACA, Interim Executive Director 
Elsie Prince, Office Manager 

MPhA Communications Committee, chaired by Chai Wang 
Graphtech, Advertising Sales and Design 


We welcome your feedback and ideas for future articles 
for Maryland Pharmacist. Send your suggestions to Kelly 
Fisher Maryland Pharmacists Association, 1800 Washington 
Bivd., Ste. 333, Baltimore, MD 21230, or email kelly. fisher@ 
mdpha.com, or call 410.727.0746 


Abidemi Adebola Adisa-Ajibowo 
Adenike Ivie Atanda 
Rebecca Carol Barnhart 
Joseph Ryan Benner 
Kimberly Gayle Bowen 
James Chang 

Teresa R. Chang 

Amy Ming Cheng 

Hae Jin Cho 

Imran Ahmad Chughtal 
Angelica Christine Agojo Dario 
Joseph Francis DiBlasi 
Amanda Loraine Eisenschmid 
Jonathan Michael Ford 
Patrick Fuh 

Nicholas Patrick Garcy 
Andrew Mason Grogg 
Natasha Gupta 

Michael Blake Hesselbacher 
Sharon Xiaoxuan Hu 

Daniela Kabatova 

Inderjeet Kaur 

Kil Joong Kim 

Gabrielle Maria Kokkinakos 
Alice Aram Lee 

Jennifer Ju Lee 

Carla Dee Lefebvre 

Nora Somatra Lim 

Kang Lin 

Betty Mal 

John Joseph McHale IV 
Christopher Kyoung-Dae Min 
Chau Quy Diem Nguyen 
Nkem Pauline Nonyel 

Stacy Michelle Ogle 

Jae Hyun Park 

Palak D. Patel 

Jessica Inez Mazur Pyhtila 


4 MH MARYLAND PHARMACIST | 


i 


Heather Maria Sellman 
Eduardo Shen 

Adam Jared Shimoda 
Christopher Lamont Smith 
Christian Magame Mba Talla 
Juliana McKenzie Tieslink 
Jacinda Thieu-Tran Nguyen Tran 
Sandy Truong 

Hsiao-Ting Wang 

Taylor Matthew Woodroof 
Kathryn Elizabeth Yee 
Hellena Getachew Admassu 
Hyo Jung Bae 

Shana Lauren Bartkowski 
Eugene Bentsianov 
Nicholas Henry Capogna 
Jennifer Chow Chang 

Jason James Chen 

Andrew Jeong Min Cho 
Jennifer Alice Cho 
Katarzyna Joanna Czerwinska 
Rohini Dinesh Dave 

Long Thanh Dinh 

Jamie Lea Elsner 

Vincent Edward Freda 
Shivani Vinay Gandhi 
Robert Bobak Gharavi 
Carmela Nicole Groves 
Rachel Niloufar Habibi 

Mikel Lamar Holley 

Anna Hung 

Godwin Chi-Fei Kam 
Thomas Njuguna Kibuthu 
Tyisha Nicole King 

Ha Vu Khanh Le 

Esther Hyun Lee 

Joo Ho Lee 

Michael Wai Ho Leung 


« 


UNIVERSITY OF MARYLAND SCHOOL OF PHARMACY 


Tae 


~ 


Bonnie Xiaojing Li-MacDonald 
Conrad Lubek 

Teresa Jan Mathe 
Michael Mehrabiansani 
Yoo Jin Elly Moon 
Kenarix Duong Nguyen 
Blair Caitlin Nuoffer 
Kalee J. Olson 

Jin W. Park 

Seemi Suryakant Patel 
Kellen O'Connor Riley 
Perry Thomas Shafner 
Steven Jeffrey Shepard 
Taylor Ryan Sibel 

Rae Christy Smith 
Namrata Thakkar Patel 
Whitney Lynn Torchia 
Quyen Bao Tran 
Stephanie Anne Walters 
Jessica Michelle Wong 
Richard Clark Wooldridge Jr. 
Carol Yun 

Frederick Asamoa-Frimpong 
Joshua Euell Bailey 
Maria Irena Bednarek 
Jessica Michele Biggs 
Jihane Chaieb 

Joni Chang 

Xing Xiu Chen 

Edward Hyungjin Cho 
Cyurry Chol 

Ofuje Daniel Daniyan 
Jennifer Marie Demeno 
John Pierce Dolan 
Kathryn Anne Finneran 
Erin Phyllis Freeman 
Claudia Alicia Garcia 
David Brandon Goffman 


Annie Guan 

Katie Beth Heavner 
Moshe Avraham Honick 
Lisa Marie Hutchins 
Bryan Jason Katz 
Angela |. Kim 

Edward Lukianos Knapp 
Jackson Le 

Hanna Michelle Lee 
Lois Lee 

Lizhi Liang 

Dennis Horng-Ru Lin 
Nirvana Astra Maharaj 
Maria Antoinette Maunz 
Jessica Ann Menachery 
Olga Naumova 

Phi Tien Nguyen 
Njualem kK. Nwelatow 
Omosigho Orise Osian 
Anjana Patel 

Serena Wei-Jung Pu 
Jiwon Roh 

Anum Ahmad Shami 
Henoke Dagnachew Shibeshi 
Ciara Camille Simon 
Sarah Kay Strausbaugh 
April Golden Thomas 
Hung Nguyen Tran 
Nicole Elizabeth Tromm 
Amanda Yang Wang 
Michael Wong 

Helen Li Jun Wu 
Stephanie Tian Zhang 
Zhongyuan Zhao 

Yijin Zhou 

Sarah Mae Zyla 


Adebukola Arike Alao 
Atanga Cyprian Alombah 
Matthew Daniel Balish 
Eric Christopher Barbye 
Bryan Aljamil Bornacelly 
Rachel Marie Bounds 
Celia Michelle Brown 
Marina Gale Byrd 

Stelios Peter Chrisopoulos 
Peter Do 

Nathalie Domo Fozeu 
Brittany Alicia Duke 
Leslie Morgan Dykes 
Elizabeth Linda Eddy 


Selasie ACkuayl 
Adetokunbo Aderibigbe 
Senait Alemu 

Melvin Atueyl 


Okechukwu Jideofor Elele 
Ji Eun 

Avraham Failaev 

Ethel Anyen Fomundam 
Benjamin David Forrest 
Margaret Waithira Githara 
Zoya B. Gutina 

Daniel Patrick Hines 
Kristen Nicole Hoang 
Shane Eric Hodges 

Kalani Cherline Hornbeak 
Abby Gayle Adebukola 
yongmu Michelle Huang 
Oluwatoyin O. Ifesanya 


Adesuwa Benedict 
Shane Borowiak 
Abhijna Chalasani 
Amanda Chan 


Lich Dang 


Alice Chong 
Janice Chung 


Katie Dantoni 


Adedamola Chris Isola 
Aleshia Maria Johny 
Camille Roxanne King 
Sandrine Nguenkeng Kojidie 
Oppong Agyare Kwateng 
Keith J. Larson 

Lucy Lee 

Duyen My Mach 

Hayatte Koulamallah McCaskill 
Courtney Murphy 
Sih-Nanga Brittany Ndumu 
Justin Douglas Ortique 
Jeremy Stanley Peterson 
Jordan Andrew Rowland 


Vivian Doan 
Christie Dunton 
Jessy Edouard 
Brittany Eisemann 


UNIVERSITY OF MARYLAND EASTERN SHORE SCHOOL OF PHARMACY 


Stephanie Mae RUSSO 
Belynda Nichole Sanders 
Kshitil Mitesh Shah 
Zachary Ryan Sherr 
Lawren Bryce Slate 
Nithin Stephen 

Tommy Lee Suh 

Samuel Turkson 

Lauren Ashley Walker 
Trevor Cullen Whiteside 


Dawit Mamushet Yifru 


Lindsey Glucksnis Musse Olani 
Wyatt Gold Oluwadamilola Oyegbile 
Lauren Griggel Priya Patel 
Phuong Ha Shaneel Patel 
Krista Hein My Pham 
Awudu Imoro Hong Phan 

Eric Isley Thu Phan 

Nadia Jabbar Brittney Saxinger 
Britney Kanemaki Preeti Sehdev 
Sharanjeet Kaur Dheera Semidey 
Katherine Kim Aenok Seo 
Soohyun Kim Fadime Seremet 
Jovon Lewis Conner Sothoron 
Andy Liu Sahar Taghvael 
Sohail Malkoukian Ting Thai 

Desiree Massari Heather Tran 
Christine Meehan Susan Tran 
Shilpa Mohan Sarah Wolfe 
Lynda Ndukwu Stephanie Zamora 
Nguyen Nguyen Zizelman 
Hang Nguyen Enela Zyka 
Afrooz Nikoobakht 

Brandon Nuziale 

jeoma Odigwe 


Kosisochukwu Odoemene 


MARYLANDPHARMACIST.ORG {ff 5 


RECOGNIZING 


Fxcellence 


Jonn Motsko & Geott Twigg 


Marsha Muhic, PharmD Candidate 2015 

University of Maryland Eastern Shore School of Pharmacy 
and 

Cynthia J. Boyle, PharmD, FAPhA, FNAP 


Professor and Chair, Department of Pharmacy Practice and Administration 


School of Pharmacy, University of Maryland Eastern Shore 


John Motsko 


Geoff Twigg 


The Maryland Pharmacists Association (MPhA) presents deserving pharmacists an array of distinguished honors 
and awards every June during the awards luncheon at the Annual Convention. This event allows the Associa- 

tion to spotlight Maryland pharmacists who are striving for excellence in pharmacy practice and promoting the 
advancement of the profession. One of the headline awards, the 2013 MPhA Excellence in Innovation Award, was 
shared by John Motsko and Geoff Twigg. They were interviewed for this article to explain how they innovated at 
their practice and to offer advice and encouragement to others. 


Award Background 


Established in 1993, this award (formerly Known as the 
Innovative Pharmacy Practice Award) aims to recognize 
forward-thinking pharmacists who have expanded their 
practices into new areas. Any practicing MPhA pharmacist 
member within the geographic area who has demonstrated 
innovative pharmacy practice resulting in improved patient 
care is eligible for nomination. The Excellence in Innovation 
Award is decided by the MPhA Past Presidents’ Council and 
supported with a stipend from the MPhA Foundation. 


6 MB MARYLAND PHARMACIST | SUMMER 2014 


Recipients Backgrounds 


John Motsko, RPh, CDE, graduated from the University of 
Maryland School of Pharmacy. He worked as an Executive 
Sales Representative in the Diabetes Division at Eli Lilly for 
over thirty-five years. Five years ago he became a Certified 
Diabetes Educator (CDE) and earned the title of Program 
Coordinator and Instructor at the Apple Drugs Diabetes 
Center. When not busy in the pharmacy, John Motsko 
spends time with his wife of 44 years, children, and grand- 
children. 


Geoff Twigg, PharmD, BCACP, CDE, earned his Doctor 
of Pharmacy degree from Shenandoah University. Before 
becoming a pharmacist, he was hired at Apple Discount 
Drugs to take out the trash and refill the soda machines. 
For the past eight years he has been a clinical pharmacist 
at that same pharmacy, working in the distinctive Diabe- 
tes Center and Medication Therapy Management (MTM) 
Services. Although his wife often tells him that he “lives and 
breathes pharmacy,” she always supports him and keeps 
him “grounded and focused.” 


Q&A with John Motsko and Geoff Twigg 


What were your thoughts when 
you heard you would be recognized 
with the MPhA Excellence in 
Innovation Award? 


Motsko: My initial thoughts were, wow, 
why us? However, when | stepped back 
and examined the impact we have 

had on patients, | thought this is great. 
Perhaps others will follow in 

our footsteps. 


Twigg: My comment to Howard [Schiff] 
when he called to tell Jonn and me 
about this honor was that it was very 
rewarding to be recognized by our 
colleagues. 


What were the most important 
steps toward your innovative 
practice? 


Twigg: The pharmacy owner, Jeff 
Sherr, was perhaps the biggest driving 
force. He has also been recognized in 
for pharmacy innovation. Jeff identifies 
problems he calls ‘work arounds’ and 
turns them into opportunities. | Know it 
was a major cost as we were starting 
out. He allowed us time to learn, 
develop, and implement our programs. 


Motsko: | guess you can break it 
down to passion, confidence, and 
most importantly, always putting the 
patient first. 


What was the major barrier for your 
innovative practice? 


Twigg: Mainly educating both our 
patients and local prescribers about the 
impact that a pharmacist can have on 
the overall health of a patient. Initially, 
many physicians viewed the pharmacist 
as a competitor rather than another 
health care provider who could help to 
augment their services. Often we heard 
from patients and prescribers alike 

that we were ‘just a pharmacy.’ We 
worked very hard to develop marketing 
materials and spend time with 
physicians. Once the local physicians 
learned how valuable a pharmacist 
could be, it Seemed they were the ones 
promoting our program for us. Another 
big hurdle was the reimbursement issue 
because a lot of insurance plans did not 
recognize MTM as a covered service. 


Motsko: We gave ‘lots of free advice.’ 


How has working on the Eastern 
Shore of Maryland brought 
opportunities, challenges, or 

a unique component for your 
innovative practice? 


Motsko: We did not have access to 
the number of providers or services 
that major metropolitan areas have. 
Geographically there are significant 
challenges for patients seeking health 
care. However, if these issues are 
identified and addressed, they can be 
overcome. Being somewhat isolated 
has enabled us to be creative out 

of necessity. 


Twigg: Often we are able to help 
patients bridge the gaps in their health 
care. Many patients remark that the first 
time they had the experience of being 
able to sit down uninterrupted and 
discuss their medications and overall 
health with a health care professional 
was in the pharmacy. 


What will it to take for your 
innovation to become a standard of 
practice? 


Twigg: Reimbursement and provider 
status. Pharmacists have so much they 
can offer the patient. However, until they 
are recognized and paid accordingly 

| fear many of the clinical services in 
community pharmacy will remain simply 
value-added services rather than the 
Standard of care. 


How were you able to use the 
award stipend from the MPhA 
Foundation? 


Motsko: | put it toward registration 
for American Association of Diabetes 
Educators (AADE) and APhA national 
conventions. 


Twigg: | attended the Philadelphia 
AADE 2013 Annual Conference. 


How do your colleagues describe 
you? 


Motsko: | think my colleagues would 
describe me as an easy going guy, yet 
someone who is very passionate about 
what he does. 


Twigg: | hope my colleagues see 
me as someone who truly enjoys his 
profession and is passionate about 
community pharmacy. 


What advice do you have for 
student pharmacists at your alma 
mater or in Maryland? 


Twigg: Always work at the top of your 
license. Continue to push pharmacy 
forward. When | graduated from 
Shenandoah, MTM was a buzzword. 

| never would have dreamed when 

| graduated that | would have the 
opportunity to do what | am doing now. 
| have been able to surround myself 
with very progressive, forward-thinking 
colleagues who are always pushing to 
expand community pharmacy. 


Motsko: Find an innovative practice 
to work with; don’t get caught up 

in the middle. Always try to be one 
step ahead of the person behind you 
and never slow down. Look for extra 
responsibilities to take on; don’t punch 
the clock and leave on the dot. Many 
patients are out there who need 

your expertise. 


You are very involved with 
pharmacy education and student 
pharmacists. What strengths and 
weaknesses do you see in today’s 
student pharmacists? 


Twigg: Students constantly impress me 
with what they are able to retain from 
classes. Some of the strongest students 
that | have had on rotations were those 
who may not have had the highest 
grades in their classes, but were able to 
spend time with patients and earn their 
trust through pharmacy interactions. 


Motsko: The skill of being able to 
communicate is paramount for success 
when working with people. 


What does your pharmacy future 
look like? 


Motsko: Pharmacy HAS TO achieve 
provider status. We have so many skills 
that could benefit patients. However, 
we have to be compensated for our 
professional services. We can improve 
the entire health care experience. 
Future pharmacists need to be prepared 
and willing to accept this newfound 
responsibility. We can make a significant 
impact in reducing health care costs, 
while improving the quality of care. 


Twigg: Pharmacists must be recognized 
as providers to help move the 
profession forward. | hope that when 
we are recognized, we will see new 
opportunities for community pharmacy. 


MARYLANDPHARMACIST.ORG {i 7 


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an educator. 
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ALL ABOUT 


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delivering excellent patient care with top 
operational performance, you understand the 
need for quality solutions and integration at 


every step along the way. So do we. 


That’s why we're combining our full suite of pharmaceutical 
management offerings to deliver solutions and insight across the 
continuum of care. Now is the time for you to concentrate on 
what matters most — your patients. 


Cardinal Health is eager to discuss your business needs. 


For more information contact one of our Pharmacy 
Business Consultants. Visit cardinalhealth.com/allaboutyou 


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© 2013 Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or 
registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Lit. No. 1RI12495 (09/2013) 


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MARYLAND PHARMACISTS ASSOCIATION 


Save the Date! 


Board of Trustees Meetings 


ber | , 
September November 


We hope to see you there! 


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Seat sar ate ; ehh, iS ae aa, A 1 


Ganiyat Awokoya Lena Choe 
Heather Beaudy Joey Mattingly 


Stay Connected! 
MarylandPharmacist.org 


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MARYLANDPHARMACIST.ORG § 


) 


Script Your Future Baltimore 
Hosts Medication Adherence 
Event for Health Care 
Professionals 


By: Script Your Future Baltimore Field Organizers p A 


ha 


Health care professionals face communication barriers when having conversations 


about the importance of medication adherence with their patients. Script Your Future 
Baltimore hosted its third Medication Adherence Experience (MAE) event on June 5 to 
address some of the communication issues faced by patients and pharmacists. 


10 §§} MARYLAND PHARMACIST | 


Script Your Future is a national campaign focused 

on increasing awareness about the importance of 

taking medications as prescribed among health care 
professionals and consumers. Introduced in 2013, Script 
your Future Baltimore's MAEs are educational events 
that bring together health care professionals from across 
the region to learn about different resources and tools 

to help communicate the vital role medication plays in 
managing chronic conditions such as diabetes, asthma, 


hypertension, and high cholesterol amongst their patients. 


On June 5, more than 50 health care professionals, 
including doctors, pharmacists, nurses, family caregivers, 
and pharmacy students attended the third MAE at the 
University of Maryland School of Pharmacy in Baltimore. 
The event focused on the quality of communication 
between health care professionals and patients in the 
retail pharmacy setting. National research findings 
Suggest that conversations that take place in this setting 
are critical to improving adherence and will lead to fewer 
and less serious health consequences. 


The event began with a networking breakfast and 
welcome remarks from Kathrin Kucharski, PharmD, 
Regional Outcomes Liaison at Sanofi. The MAE program 
then opened with a patient panel discussion moderated 
by Cherokee Layson-Wolf, PharmD, Associate Dean of 
Student Affairs at the University of Maryland School 

of Pharmacy. Three patients with chronic conditions, 
such as diabetes and respiratory disease, discussed 
their interactions with health care professionals and 
their medication-taking behaviors. Additionally, Dr. 
Nicole Brandt, PharmD, University of Maryland School 
of Pharmacy, joined her patient to discuss the woman's 
experience with juggling a complex medication regimen. 


Following the panel discussion, CARE Pharmacies’ 
Karen Kuczynski, Director of Marketing and Business 
Development; along with Kunjal Patel, PharmD, 
pharmacist at Arundel Mills CARE Pharmacy; and Sam 
Stolpe, PharmD, Pharmacy Quality Alliance (PQA) took 
the podium to discuss new strategies for measuring and 
improving adherence in retail pharmacies. Walgreen's 
Sade Osotimehin, PharmD, concluded the event by 
presenting examples and practices for making the most 
of pharmacists’ often-brief interactions with patients at 
the pharmacy counter by applying Medication Therapy 
Management principles to conversations. 


The third MAE was made possible by members of 

the Script Your Future Baltimore coalition and event 
sponsors, including the title soonsors — the Maryland 
Public Health Association and Novo Nordisk, along with 
in-kind sponsors — the University of Maryland School of 
Pharmacy and the Delmarva Foundation. 


To learn more about Script Your Future Baltimore, please 
visit: http://www.scriptyourfuture.org/pilot-cities/, or 
contact Kerry Owens at kowens@mghus.com. 


Photo credits this page: University of Maryland School of Pharmacy and Script Your 
Future Baltimore . 


Sam Stolpe, PharmD, 
Pharmacy Quality Alliance 
(PQA) 


e2 


oie 
l=) o 


Script Your Future Baltimore Coalition (left to right): Katie Grieco, 
Script Your Future Baltimore field organizer; Rebecca Burkholder, 
National Consumers League; Cherokee Layson-Wolf, University 
of Maryland School of Pharmacy; Kathrin Kucharski, Sanofi; 
Jennifer Thomas, Delmarva Foundation; Karen Kuczynski, CARE 
Pharmacies; and Kelly Cahill, Script Your Future Baltimore field 
organizer. 


Patient Panel (left to right): Reggie Bishop, patient; 

Dr. Nicole Brandt, PharmD, University of Maryland School of 
Pharmacy; June Kimmelshue, patient; and Robert Gaskins, 
patient. 


MARYLANDPHARMACIST.ORG if 11 


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12 §§ MARYLAND PHARMACIST | 


Natalie D. Eddington, PhD, FAAPS, FCP dean and professor at the University 

of Maryland School of Pharmacy was appointed executive director of University 
Regional Partnerships. Dr. Eddington will assist the University’s senior vice 
presidents and deans regarding issues on expansion of the University’s academic 
and research programs in Montgomery and Prince George’s counties. 


Brian Hose, PharmD, pharmacist and owner of Sharpsburg Pharmacy, was 
inducted into the Dean’s Hall of Fame for Distinguished Community Pharmacists 
as part of the annual banquet hosted by the University of Maryland School of 
Pharmacy’s National Community Pharmacists Association student chapter on 
April 24. This award recognizes a pharmacist’s leadership, entrepreneurship, and 
passion for independent pharmacy. Brian is the youngest community pharmacist 
to receive the award. 


Congratulations! Chai Wang and Deanna Tran were married on May 3, 2014 at 
the Chesapeake Bay Beach Club in Stevensville, MD. Chai is chair of the Legislative 
and Communications Committees and Deanna is co-chair of the New Practitioner 
Network. The couple graduated from the University of Maryland School of 
Pharmacy in 2011. 


Clockwise from top: Natalie D. Eddington, 
Brian Hose, Chai Wang and Deanna Tran 


Do you have good news to share? 
Send your Member Mention to kelly.fisher@mdpha.com. 


Please enclose a photo if possible. 


MARYLANDPHARMACIST.ORG { 13 


ual 


Navigating the CHaneine Tides of Pharmacy 
Clarion Resort Fontainebleau Hotel 
Ocean City, MD 


Some highlights of the Convention 


To see all the pictures from the 132nd Annual Convention, visit the MPhA Facebook page! 


14 MM MARYLAND PHARMACIST | 


15 


ned 


Co 


al 


MARYLANDPHARMACIST.ORG 


ways a great time — Annual Crab Feast and Seacrets! 


Al 


Pharmacy in Excellence Awards Luncheon 
Monday, June 16, 2014 


Oe 19, a7 ee, 
to the 2014 Recipients! 


Seen nine tuen acc con 


3 ss = = pe a AG a a ‘ e a 
Jane Kim and Brandon Chai Wang is recognized Deanna Tran graciously Chairman Brian Hose is 
Nuziale (not pictured) are for his service to the accepted the Distinguished recognized with the MPhA 
the recipients of the MPhA Association as Outgoing Young Pharmacist Award Mentor Award. 
Scholarship Awards presented Speaker of the House. from Pharmacists Mutual 
by MPhA President Christine Companies representative 
Lee-Wilson. Stephanie Dave DeFelice. 


Southard (not pictured) is 
the recipient of the MPhA 
Foundation Scholarship Award. 


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SX SS VaR. Ved 
Hoai-An Truong is honored with Bethany DiPaula_ Lynette Bradley Baker Mary Lynn McPherson is 
the Excellence in Innovation Award is honored with is recognized as MPhA‘s recognized with the Seidman 
presented by MPhA Foundation the Cardinal 2014 Honorary President — Distinguished Achievement 
President Paul Holly. The award Health Generation — by Interim Executive Award with her husband. 
is sponsored by Upsher-Smith Rx Champions Director Dixie Leikach. 
Laboratories, Inc. Award. The award 


is sponsored by 
Cardinal Health 
Foundation. 


16 MB MARYLAND PHARMACIST | 


Bowl of Hygeia 2014 Award Winner 


Donald Taylor is presented with the Bowl of Hygeia Award, 
considered the most prestigious award in the pharmacy 
profession, by Arnold Honkofsky. The award is sponsored by 
APhA Foundation and NASPA. Boehringer Ingelheim is the 
premier supporter. 


Award Background 


Established in 1958, the Bowl of Hygeia Award recognizes 
pharmacists who possess outstanding records of civic leadership 
in their communities and encourages pharmacists to take active 
roles in their communities. In addition to service through their 
local, state, and national pharmacy associations, award recipients 
devote their time, talent, and resources to a wide variety of 
causes and community service. Any MPhA member pharmacist 
who has not already received the Bowl of Hygeia Award is eligible 
for nomination. 


The Bowl of Hygeia is the most widely recognized international 
symbol for the pharmacy profession. The Bowl of Hygeia has been 
associated with the pharmacy profession since as early as 1796, 
when the symbol was used on a coin minted for the Parisian 
Society of Pharmacy. The bowl represents a medicinal potion and 
the snake represents healing. 


We are grateful for our generous 


Convention Contributors 


who helped make the 132nd Annual Convention a success 


Abbott Diabetes Care CCGP NCPA 
A&M Printing CVS Caremark Nutramax Laboratories, Inc. 
AmerisourceBergen Dr. Gordshell’s Paas National 
APhA Foundation EPIC Pharmacies PEAC 
ASCP Hisamitsu America Pharmacists Mutual Companies 
Atlantic Financial Federal Credit Kasier Permanente PharmCon 

Union Kleins Shop Rite Pharmacy Purdue Pharma 
Boehringer Ingelheim Match Rx Rite Aid 
BSM Medical Mayer & Steinberg Shoppers Pharmacy 
Calmoseptine, Inc. Merck & Co. Target Marketing 
Cardinal Health Foundation Mission Pharmacal UMB SOP 
Care Pharmacies, Inc. MPhA Foundation Walgreens 
Catonsville/Finksburg Pharmacies NASPA aloe 


MARYLANDPHARMACIST.ORG 17 


Meet Your 2014/2015 Board of Trustees 


The 2014/2015 Board of Trustees was installed during the 132nd Annual Convention on Sunday, June 15, 2014. Thank you all 
for your time and dedication to the Association. MPhA looks forward to your jisaaaiae and palette you all carry out our 
mission throughout the next year. - Nae 


“Promote excellence in pharmacy practice, 
Strengthen the profession of pharmacy, and 
advocate for all Maryland pharmacists.” 


From left to right: Kristen Fink, Trustee; Mark 
Lapouraille, Trustee; Matt Shimoda, Treasurer; 
Nicole Culhane, Trustee; *Chris Charles, Vice 
Speaker of the House; *Cherokee Layson-Wolf 
Trustee; Larry Hogue, Speaker of the House; 
*Ashley Moody, Trustee; Hoai-An Truong, 
President-Elect, *Nghia Nguyen, ASP Student 
Representative, Christine Lee-Wilson, President; 
Brian Hose, Chairman; Matt Shimoda, Treasurer; 
*Cherokee Layson-Wolf Trustee; | 

Nicole Culhane, Trustee; *Ashley Moody, Trustee. 
Not pictured: Wayne VanWie, Trustee 


*Newly installed 


CALLING ALL AUTHORS! 


Write or 77 calend Méarmaci 


We are looking for authors for the following journal sections: 


e Technician Corner e Experience e Professional 


Event Promotion 
e Research Reports e Member Spotlight ‘ 


| | e Other (Contact us 
e Review Articles e Commentary with ie ideas!) 


e Case Reports e Pharmacy History 


Interested? Contact Kelly Fisher: Kelly.fisher@mdpha.com 


Journal Submission Guidelines can be found at marylandpharmacist.org under 
“Communications” heading 


WE NEED YOUR SUBMISSIONS! 


18 9B MARYLAND PHARMACIST | 


«| CONTINUING EDUCATION 
Samuel Houmes, PharmD 
PGY 1 Community Pharmacy Resident 


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A Review of the Evidence Regarding 
Fish Oil Supplementation 


Healthcare practitioners’ field questions daily from patients about whether a specific supplement is 
right for them or not. A question commonly asked by patients is whether fish oil would be beneficial 
to prevent heart disease. A few years ago the answer would have been easy, with a resounding “Yes.” 
However, practitioners listening to recent news may begin to reconsider as select trials have found 
conflicting results. When comparing previous to current trials on the benefits of fish oil, it is easy to 
become confused. This article will aid in providing clear evidence about fish oil supplementation. 


Learning Objectives: After reading this article, the learner will be able to: 
1. Identify labeled and unlabeled indications for fish oil Supplementation. 


2.Summarize two key differences between studies involving fish oil supplementation in cardiovascular, 
cerebrovascular, and dysglycemia disease states. 


3. Given a patient case, be able to correctly determine if fish oil supplementation is appropriate. 


Key words: Supplementation, Fish oil, Cardiovascular disease 


What IS Fish Oil? term “fish oil” refers to specific types recommended daily allowance (RDA) 

| DHA depends on the 
What exactly constit fish Oil? of PUFAS such as eicosapentaenoic for EPA and 
in one sae ace acid (EPA) and docosahexaenoic guidelines consulted. The American 
recommend the use of fish oil. the acid (DHA). By using these particular Heart Association (AHA) recommends 
intent is adding a long polyunsaturated fatty acids the patient will have patients without documented heart 
fatty acid (PUFA, also known as more than the recommended daily disease consume at least two servings 
omega-3’s) to the patient's regimen. allowance (RDA) of EPA and DHA Continued on page 20 


When used as a supplement the normally obtained from the diet. The 


MARYLANDPHARMACIST.ORG ff 19 


(3-3.5 ounces) of fresh fish per week.? 
One gram of combined EPA and 

DHA either from supplementation 

or diet is recommended by the AHA 
in patients with heart disease. In 
patients with hypertriglyceridemia, 
defined as serum triglycerides greater 
than 500 mg/d3, the recommended 
dose is three to four grams daily.? It 

is important to consult the over-the- 
counter fish oil Supplement labeling 
to verify the amount of EPA and DHA 
milligram content per capsule. 


Many different types of fish oil 
products are available, as both 
over-the-counter and prescription 
Supplements. Lovaza® and Vascepa® 
are available by prescription and are 
both FDA-approved to treat patients 
with hypertriglyceridemia.24 Because 
these agents require a prescription, 
they have much stricter regulations 
concerning their manufacturing 
process. For example, the dose listed 
for the product correlates to the dose 
observed if the capsule was submitted 
for laboratory testing. In contrast, 
over the counter Supplements are not 


Table 1: Methods and Outcomes er 


subject to the same strict standards 
required for prescription products. This 
becomes evident after reviewing the 
Consumer Lab (CL) report for fish oil 
products. The CL is an independent 
agency that tests over-the-counter 
products for their claimed dosage, 
purity, spoilage, and other parameters 
specific to the over the counter 
product.° Some fish oil products 
tested by the CL have excellent 
results, showing that the dosage for 
these products was appropriate and 
the product was pure and free from 
spoilage. Other products tested by the 
CL were not as pure. These products 
could have displayed dosages of 

less than 80% to greater than 260% 
of the claimed milligram content of 
EPA and DHA.° The products could 
also have contained unacceptable 
levels of harmful contaminants, likely 
a problem of poor manufacturing 
standards or suboptimal raw 
materials.® 


Pharmacologic Effects 
The mechanism of action for fish 


Outcome 


Study & Author(s) Study Purpose 
GISSI-P"” Fish oil vs. Vitamin E vs. Treatment groups that included 
Valagussa combination vs. placebo for fish oils as part of their 


primary prevention 


—______________ 
Fish oil with or without statin 
vs. placebo with or without 


GISSI-HF"® 
GISSI Investigators 


intervention had a 10% risk 
reduction in cardiovascular 
fish oils as part of their events 


Small benefit for fish oil 
treatment 


Statin for prevention of 
morbidity and mortality in 


heart failure 


—_______________ 
Fish oil plus statin vs. statin 
alone for major coronary 


event prevention 
—__________ 


Fish oil vs. placebo for 
secondary prevention in 


JELIS2 


n-3 and Dysglycemia”° 


diabetics 


n-3 and Cardiovascular 
Risk Factors?! 
Collaborative Group 


prevention 


—______________ 
Fish oil vs. placebo for 
secondary prevention 
_—___________ a 


n-3 and Post-MI” 
Alpha Omega 


20 MB MARYLAND PHARMACIST | SUMMER ; 


Fish oil group had a 19% risk 
reduction in major coronary 
events 


No difference in primary or 
secondary outcomes 


Fish oil vs. placebo for primary —_No difference in primary or 


secondary outcomes 


No significant benefit observed 


27014 


oils has yet to be clearly elucidated. 
Studies have shown that fish oil has a 
wide range of actions physiologically. 
Fish oil has been observed to have the 
following effects: 


e Lipids—decreases triglycerides and 
increases high-density and low- 
density lipoproteins® 


e Arterial compliance 
e Endothelial and platelet function’ 


e Blood pressure—decreases systolic 
and diastolic pressures by 3-5 and 
2-3 MMHg respectively® 


¢ Coagulation—causes minor 
increases in bleeding time have 
been observed’ 


e Diabetes—possible effect on fasting 
blood glucose? 


e Cardiac function—decreases heart 
rate by roughly 2.5 bpm’? 


e Electrophysiology”® 


e Effect on inflammatory factors— 
both EPA and DHA play a role as 
precursors to eicosanoids and other 
inflammatory mediators" 


Therapeutic Effectiveness 


Unfortunately, fish oil supplementation 
does not have a clearly defined place 
in therapy. For example, the Adult 
Treatment Panel (ATP) 4 cholesterol 


- guidelines do not recommend 


Supplementation with fish oil in the 
context of cardiovascular disease 
prevention.'? The European Heart 
Journal and American Diabetes 
Association recommend fish oil may 
be used as an agent to help with 
triglyceride lowering, '*"4 although 
only the European Heart Journal lists 
a suggested dose for this indication.’9 
Both of those guidelines word their 
recommendation very lightly, stating 
they prefer dietary intervention and to 
use supplementation only if necessary. 
The American Association of Clinical 
Endocrinologist guidelines mention 
fish oil has a possible role in reduction 
of atherosclerotic plaque growth, as 
well as triglyceride-lowering (with a 
dose listed in addition), but only as 


an adjunct agent.'° Again, in these 
guidelines, dietary sources are 
preferred over supplementation. 


The beginning of disease-prevention 
fish oil Supplementation can be traced 
to a population study conducted in 
the 1980's evaluating the nutritional 
status of Eskimos. The researchers 
noticed a low baseline level of 
cardiovascular disease within the 
study population.’ Upon comparison 
to other populations, they found a 
proportionally higher level of fish 
consumed within the Eskimo’s diet, 
and the amount of fish oil consumed 
was calculated to be approximately 
250-500 mg of EPA and DHA." After 
analysis of this trial, researchers 
began to question whether supple- 
mentation with fish oil could reduce 
cardiovascular risk. Multiple trials 
were conducted, including the 
Gruppo Italiano per lo Studio della 
Soprawivenza nell’Infarto miocardico- 
Prevenzione (GISSI-P), GISSI-HF, and 
the Japan Eicosapentaenoic Acid 
Lipid Intervention Study (JJELIS). Refer 
to Table 1 for a comparison of the 
methods and outcomes of these 
trials.1722 These trials helped to form 
the original basis of evidence for fish 
oil supplementation. 


The GISSI-P trial was conducted to 
determine if drug-equivalent PUFA 
and vitamin E were as protective 

as fish consumption by comparing 
dietary habits to a supplement- 
based intervention for prevention 

of myocardial infarction. The study 
enrolled patients who had a recent 
MI without age limits and randomized 
them into open-label treatment 
groups. One group received placebo 
treatments, one group received 300 
meg Vitamin E, one group received 
850-882 mg EPA and DHA, and 

the final group received both of 

the intervention treatments (the 
combination of 300 mg Vitamin E and 
850-882 mg EPA and DHA). At the 
conclusion of the trial, the researchers 
noticed that the treatment groups 
which included fish oils as part or 

all of the intervention had a relative 
10% risk reduction in cardiovascular 
events, such as death, nonfatal 
myocardial infarction, or stroke over 
the treatment groups without fish 


Oil. This 10% risk reduction was also 
observed for secondary fatal events, 
cardiovascular disease, and coronary 
heart disease.” 


The GISSI-HF trial assessed reductions 
in hospital admissions for patients 
with congestive heart failure taking 

1 gram of fish oil daily. The study 
enrolled patients with New York Heart 
Association Class II-IlV regardless of 
cause, and assigned patients to either 
1 gram of fish oil daily or placebo. 
After the trial was completed, the 
researchers observed a hazard 

ratio of 0.91 (p=0.041) for the fish 

oil treatment and 0.92 (p=0.009) for 
the placebo treatment, suggesting a 
small benefit for fish oil. The authors 
calculated a number needed to treat 
(NNT) of 56 patients treated with fish 
oil for 3.9 years to avoid one death, 
or 44 patients to avoid one event 
such as death or admission due to 
cardiovascular cause. '® 


The JELIS trial evaluated the primary 
prevention of coronary artery 
disease with long-term use of fish 

oil in hypercholesteremic patients. 
Participants were randomly assigned 
to receive 1800 mg of EPA daily fish 
oil or placebo. Both groups were 
concurrently taking statin therapy. The 
primary endpoints were any major 
coronary event and non-fatal events 
such as unstable angina, angioplasty, 
stenting, or coronary artery bypass 
graft (CABG). Upon data examination, 
the authors noted patients in the fish 
oil intervention group with a history 
of coronary artery disease had an 
approximate 19% risk reduction 

in major coronary events, defined 

as non-fatal myocardial infarction, 
unstable angina, and events of 
angioplasty, stenting, or coronary 
artery bypass grafting.” These three 
trial observations conflict with the 
following trial conclusions concerning 
fish oil Supplementation. 


The purpose of the ORIGIN trial, 
published in 2012, was to determine 
if long-term fish oil supplementation 
would decrease cardiovascular events 
in diabetic populations.” It was a 
randomized control trial and included 
patients who were 50 years or older, 
had diabetes or an impaired fasting 


glucose or impaired glucose tolerance 
test, a previous myocardial infarction 
(MI), stroke, revascularization, angina, 
microalbuminuria, left ventricular 
hypertrophy, a 50% stenosis of a 
coronary artery, or an ankle-brachial 
index less than 0.9. Patients were 
excluded if they were unwilling to 
stop current fish oil use, had an 
hemoglobin A1c >9%, a coronary 
artery bypass graft (CABG) in the 
previous four years, heart failure, or 
a cancer diagnosis that may have 
affected survival during the course of 
the trial. Patients were randomized 
to an olive oil placebo or to 1 gram 
of combined EPA and DHA daily. The 
primary study endpoint was death 
from cardiovascular cause. Secondary 
endpoints included the composite 

of death from cardiovascular cause, 
nonfatal MI, nonfatal stroke, death 
from any cause, or death from 
arrhythmia. The research team 
observed no significant difference 

in both primary and secondary 
outcomes. Upon generation of 
Kaplan-Meier survival curves, the 
data points for both the intervention 
group and placebo group appear to 
overlap, further Suggesting fish oil 
supplementation provided no benefit 
in this study population.”° 


The Risk and Prevention Study 
Collaborative, published in 2013, 
studied whether fish oil would display 
a risk reduction in patients with 
multiple cardiovascular risk factors." It 
was a randomized, placebo controlled 
trial that included participants with 
four or more of the following, or 

in patients with diabetes having 

at least one of the following: 65 

years old or older, male, preexisting 
hypertension or treatment, preexisting 
hyperlipidemia or treatment, smoking, 
obesity, family history of premature 
disease in a male relative less than 

55 years old (or a female relative 

less than 65), atherosclerotic disease 
(defined as angina, peripheral artery 
disease, a history of stroke or a 
transient ischemic attack, or a prior 
revascularization) or the practitioner 
held the opinion the patient had a high 
cardiovascular disease risk. Exclusion 
criteria included a past history of MI, 


Continued on page 22 


MARYLANDPHARMACIST.ORG ff 21 


a fish oil allergy, current pregnancy, 
an inability to give informed consent, 
or poor short term prognosis affecting 
Survival during the trial. Patients were 
randomized to receive either one 
gram of fish oil or placebo olive oil. The 
primary study endpoint was originally 
planned as a cumulative rate of death, 
nonfatal MI, or nonfatal stroke, with 
secondary endpoints of composite of 
time to death, death from CHD, and 
sudden death from cardiac cause. 
These were changed to primary 
endpoints of time to death from CV 
Cause, or hospital admission for CV 
cause, with secondary endpoints 
compromising the original secondary 
endpoints with the previous primary 
endpoints. This change occurred 
mid-study due to participants not 
meeting the expected event rate for 
the trial. As in the ORIGIN trial, this 
trial observed no significant difference 
in primary or secondary endpoints. 
Again, on Kaplan-Meier survival curves 
the data points for intervention and 
placebo groups appear to overlap, 
signifying no major difference 
between treatments. Notably, upon 
Subgroup analysis in this trial two 
instances were found where fish oil 
Supplementation provided a small 

but significant benefit. The research 
team noted the hospitalization 
admission rate for patients with heart 
failure taking fish oil was lower and 
also found female patients taking 

fish oil Supplements were less likely 
to be admitted to a hospital for a 
Cardiovascular cause, and had a lower 
risk of death overall.’ 


The Alpha Omega trial was completed 
to determine whether low-dose fish 
oil and/or alpha-linoleic acid (ALA, 

a precursor to EPA and DHA) had a 
risk reduction effect in patients who 
already had a myocardial infarction.22 
It was a randomized control trial 
which included patients aged 60-80 
years old with a clinical diagnosis of 
MI in the past decade. Participants 
were excluded if they were unable 
to consume less than 10 grams of 
margarine daily (for reference, one 
stick of butter is approximately 110 
grams), prior or current use of fish 
oil, an unintended weight loss, or 

a cancer diagnosis with less than 


22 MB MARYLAND PHARMACIST | SUMMER 


one year of life expectancy. The 
placebo group received margarine 
containing the recommended daily 
values of EPA, DHA, and ALA. The 

fish oil intervention group received 
RDA plus 400 mg of fish oils. The ALA 
intervention group received RDV plus 
2 grams of ALA. A third combined 
intervention group received RDV 

plus 400 mg of fish oils and 2 grams 
of ALA. The primary endpoints for 

the study included non-fatal or fatal 
cardiovascular disease, percutaneous 
coronary intervention, or CABG. 
Secondary endpoints included inci- 
dent cardiovascular disease, fatal 
Cardiovascular disease, fatal coronary 
heart disease, ventricular-arrhythmia 
related events, and death from any 
cause. Across all of the groups, no 
Significant benefit was observed 

in the fish oil, ALA, or combined 
intervention groups over placebo. In 
the Kaplan-Meier survival curves, the 
data points were again overlapping 
through the course of the study. ALA 
appeared to have a slight advantage 
in the Kaplan-Meier survival curves for 
major CV events in women towards 
the end of the study, but this was not 
significant prior to trial conclusion. The 
research team did conduct a post- 
hoc exploratory analysis of patients 
with and patients without diabetes. 
Within the diabetic subgroup, there 


were statistically significant reductions 
in incident cardiovascular disease, 
death from coronary heart disease, as 
well as ventricular-arrhythmia-related 
events. These risk reductions were 
observed for both the fish oil and ALA 
intervention groups. The authors noted 
that even though the significance of 
the data was comparable to the data 
observed in the GISSI-P trial, this was 
only noticed after unblinding of the 
data: 


So What's the Bottom Line? 


Considering all of this information, it is 
difficult to draw definitive conclusions 
based on the data. When closely 
examining the trials, many differences 
are noted. First, the trials all had 
different stated purposes (refer to 
Table 1)'7?2. To definitively refute a 
scientific claim, a study would have 

to be conducted in the same manner 
and find conflicting results. Since this 
did not occur, the conflicting results 
may be viewed with caution. When 
considering the outcomes of a primary 
prevention trial, it is difficult to make 

a Claim on secondary prevention 
effects, or to extrapolate results from 
a specific study population to all 
populations or for different indications. 


Another point of contention is the 
recording and use of concurrent 


Study & Author(s) —ACE-I/ARB 

Greenland Eskimos'® — — — — 
GISSI-P" Yes Yes Yes No 
Valagussa 

GISSI-HF'® Yes Yes Yes Yes 


GISSI Investigators 


a 


JELIST Yes 
Yokoyama 

n-3 and Dysglycemia?° Yes 
ORIGIN Trial 


ee eee 


n-3 and Cardiovascular Yes 
Risk Factors?! 


Collaborative Group 
n-3 and Post-MI?2 Yes 


Kromhout 


ee 


2014 


Table 3: Study Differences 
Study & Author(s) 


Dietary Fish Fish Oil Dose Follow-up 
Greenland Eskimos'® 30 grams fish/daily — _— 
GISSI-P"” Not studied 850-882 mg 42 months 
Valagussa EPA:DHA:* no data 
Ratio: 1:2 
GISSI-HF"® Not studied 850-882 mg 36 months 
GISSI Investigators EPA:DHA: no data 
Ratio: 1:2 
JELIS'® Not studied 1800 mg 48-72 months 
Yokoyama EPA alone, no DHA 
n-3 and Dysglycemia”’ Not studied 1 gm. 72-96 months 
Bosch EPA:DHA ~84% 
Ratio: 1.2:1 
n-3 and Cardiovascular Not studied 1 gm. 60 months 
Risk Factors?! EPA:DHA: >85% 
Roncaglioni Ratio: 0.9-1.5:1 
n-3 and Post-MI”? Not studied RDV** + 400 mg 40 months 


Kromhout 


EPA:DHA: ~3% 
Ratio: 3:2 


eee 000 = 


*EPA — eicosapentaenoic acid. DHA — docosahexaenoic acid 


**RDV — recommended daily value 


cardioprotective therapies (refer to 
Table 2). Unfortunately, in comparison 
to the ORIGIN, Aloha Omega, and 

Risk Prevention trials, the early 

trials were not as consistent with 

the use of statins.2°2"2 During the 
GISSI-P study, statin therapy was not 
considered appropriate standard of 
care.” In GISSI-HF, patients were also 
randomized to either placebo or 10 
meg of rosuvastatin (in addition to 
receiving fish oils or placebo as well)."® 
The JELIS trial was the only early trial 
assessing the comparison of benefit 
in statin and placebo combination 
treatment versus statin (10-20 mg of 
pravastatin or 5-10 mg of simvastatin) 
and fish oil.’? Given that each of the 
early trials displayed a benefit in favor 
of fish oil and each of the recent 
trials, with notably increased use of 
Statins and at higher dosages, 79°17 
found little or no benefit of fish oils, 

a question arises about the impact 

of statin therapy on cardiovascular 


disease and prevention. Although the 
benefits of statin therapy alone have 
been well documented, the core issue 
is if the addition of fish oils provides 
additional benefit when combined 
with statin therapy. 


The amount of study follow-up was 
notably different between trials (refer 
to Table 3). Follow-up periods with the 
trials ranged from 40 months up to 
96 months. While not extraordinarily 
different, the amount of time each 
trial had to observe event rates is 

an important factor to consider 
before comparing trials on a head to 
head basis. 


Assessment of dietary habits and 
fish consumption was not rigorously 
controlled in each of the clinical trials 
(see Table 3). For example, each of 
the trials described an attempt to 
control a participant’s diet during 

the course of the study through the 
use of dietary counseling. However, 


properly assessing dietary habits is 
difficult in these larger studies. In order 
to completely and accurately assess 

a patient's dietary habits, it would 
require constant observation of the 
participant enrolled in a trial. This is 
not feasible, as it would require either 
institutionalization of the participant or 
require a team member to observe the 
individual all day. While less than ideal, 
questionnaires allow for subjective 
assessment of dietary habits. This, 
however, inevitably decreases the 
quality of the data recorded and 

could be considered a confounding 
factor. Another factor is the use of 
Olive oil in the recent trials.*°" It has 
been well documented that olive oils 
have beneficial effects on health as 
demonstrated in the Mediterranean 
diet. The recent trials null results could 
be exaggerated by the use of an olive 
oil, which has protective heart effects. 


A final inconsistency between trials 
was the fish oil dose utilized for 

each study (refer to Table 3). Both 

the total dose of fish oil used for 
Supplementation, as well as the ratio 
of EPA to DHA varied among the trials. 
These inconsistencies make it difficult 
to compare trial results. 


What's The Bottom Line? 


Based on the currently available 
evidence, a clear recommendation 

is difficult to determine. An accurate 
recommendation for patients inquiring 
about the use of fish oil may be that 
the addition of fish oil to their current 
drug regimen would likely not provide 
a risk reduction benefit. Having 

said that, the patient may choose 

to pursue fish oil supplementation 
despite the lack of strong beneficial 
evidence particularly since fish oil 
has a relatively benign side effect 
profile. As with all dug therapy, 
benefits and burdens of therapy 

must be considered, including the 
financial cost of therapy. Ultimately, to 
assess the true benefit of fish oils on 
cardiovascular disease prevention vs. 
the current standard of care, a head 
to head trial comparing statin therapy 
alone to statin therapy with added fish 
oil would be needed. 


Continued on page 24 


MARYLANDPHARMACIST.ORG i 23 


Sidebar Case: “Clearly Confused” 


AT is a 58 year old African American woman who approaches the pharmacy counter with a bottle of fish oil in 

hand. She asks to speak with the pharmacist, and inquires whether or not fish oil will help her stay healthy. Luckily, 
she gets all her medications at this pharmacy, and just-so-happens to have her most recent lab results from her 
primary care visit. She states she has a past history of hypertension, diabetes, dyslipidemia, migraines, and seasonal 


allergies. She reports both her mother and father had a history of heart disease. 


pose Tove 
Famine [eaten [yaaa 


Excedrin Migraine | 250/250/65 mg 


DRUG DOSE 


QUESTION 1 


What recommendation would you 
give AT whether she should start 
taking fish oil? 


a. AT should start taking fish oil at a 
dose of 4 grams daily. 


b. AT should start taking fish oil at a 
dose of 1 gram daily. 


c. AT does not need to take fish oil. 


d.AT should bring this question up 
at her next visit with her primary 
Care physician. 


QUESTION 2 


At what serum triglyceride level 
would fish oil supplementation 

be considered appropriate for 
treatment of hypertriglyceridemia? 


a. > 250 mg/dL 
b.> 500 mg/dL 
c.> 750 mg/dL 
d.> 1000 mg/dL 


24 MB MARYLAND PHARMACIST | 


Take 1 by mouth at bedtime 
Take 1 by mouth once daily as needed 


Take 2 by mouth every 6 hours 
as needed. Maximum of 8 per day 


QUESTION 3 


What counseling would you offer to 
AT if she chooses to begin fish oil 
supplementation today? 


a. She can expect a lowered lifetime 
risk for cardiovascular disease. 


b. She can expect to see a decrease 
of her low-density lipoprotein 
serum concentrations. 


c. She likely will be taking a 
supplement without proven 
risk reduction in cardiovascular 
disease states. 


d.She may notice her blood 
pressure and heart rate 
will increase while taking 
supplements. 


The answer to question? is “C.” 
Based on the analysis of the Alpha 
Omega, Risk Prevention, and 
ORIGIN trials, cardiovascular risk 
reduction does not appear to be 
Clinically or statistically significant 
with fish oil supplementation. D is 


LABS 


Blood Pressure — 128/78 mmHg 


Heart Rate — 65 bpm 


Respiratory Rate — 15 bpm 


Total Cholesterol — 187 mg/dL 


HDL — 48 mg/dL 


LDL — 105 mg/dL 


Triglycerides — 168 mg/dL 


Hemoglobin Alc — 6.4% 


incorrect, because pharmacists are 
clearly able to accurately answer 
questions about supplements. 

A is the approved dose for 
hypertriglyceridemia treatment. B is 
a dose recommended by the AHA 
for patients with heart disease. 


As discussed in the article, 

the clinical definition of 
hypertriglyceridemia is a serum 
triglyceride level above 500 mg/dL, 
therefore the answer is “B.” 


Regarding question 3, the Alpha 
Omega, Risk Prevention, and 
ORIGIN trials did not display 
cardiovascular risk reduction, 
therefore A Is incorrect. B is 
incorrect because LDL levels are 
expected to increase with fish oil 
Supplementation. Likewise, D is 
incorrect because select studies 
showed a decrease in blood 
pressure and heart rate with 
Supplementation. Therefore the 
correct answer is “C.” 


Resources on page 25 


CONTINUING EDUCATION QUIZ 


PharmCon is accredited by the Accred- 
itation Council for Pharmacy Education 


as a provider of continuing pharmacy 


education. A continuing education 
credit will be awarded within six to 
eight weeks. 


Program Release Date: 7/8/2014 
Program Expiration Date: 7/8/2017 


This program provides for 1.0 contact hour (0.1) of 
continuing education credit. Universal Activity Number 


(UAN) 0798-9999-14-120-H01-P 


The authors have no financial disclosures to report 


This program is Knowledge Based — acquiring factual 
knowledge that is based on evidence as accepted in the 
literature by the health care professionals. 


REFERENCES 


af 


Mayoclinic.org. Omega-3 fatty acids, fish oil, 
alpha-linoleic acid. 2013 Nov 1. Available from: 
http://www.mayoclinic.org/drugs-supplements/ 
omega-3-fatty-acids-fish-oil-alpha-linolenic-acid/ 
background/hrb-20059372. Accessed March 1, 
2014. 


American Heart Association. Fish 101. 2014 Feb 21. 
Available from: http://www.heart.org/HEARTORG/ 
GettingHealthy/NutritionCenter/HealthyEating/ 
Fish-101_UCM_305986_Article.jsp. Accessed 
March 15, 2014. 


GSK. Lovaza prescribing information. 2013 June. 
Available from: http://us.gsk.com/products/assets/ 
us_lovaza.pdf Accessed March 15, 2014. 


Amarin Pharma. Vascepa prescribing information. 
2013 November. Available from: http://www.vasce- 
pa.com/full-prescribing-information.pdf Accessed 
March 15, 2014. 


Consumer lab report for fish oil. Available from: 
http://www.consumerlab.com/review/fish_oil_sup- 
plements_review/omega3. Accessed March 15, 
2014. 


Harris WS, Bulchandani D. Why do omega-3 fatty 
acids lower serum triglycerides. Curr Opin Lipidol. 
2006 Aug:17(4):387-93. 


Knapp HR, Reilly IA, Alessandrini P. FitzGerald GA. 
In vivo indexes of platelet and vascular function 
during fish-oil administration in patients with 
atherosclerosis. N Engl J Med 1986;314(15):937. 


Geleijnse JM, Giltay EJ, Grobbee DE, Donders AR, 
Kok FJ. Blood pressure response to fish oil supple- 
mentation: metaregression analysis of randomized 
trials. J Hypertens. 2002;20(8)1493. 


Friedberg CE, Janssen MJ, Jeine RJ, Grobbee DE. 
Fish oil and glycemic control in diabetes. A me- 
ta-analysis. Diabetes Care. 1998;21(4)494. 


10. 


WZ 


14. 


ite} 


WE 


. James MJ, Gibson RA, Cleland LG. Dietary polyun- 


Directions for taking this issue’s quiz: 


This issue’s quiz on Swimming in Circles? A Review of 
® the Evidence Regarding Fish Oil Supplementation can 
be found online at www.PharmCon.com. 


(1) Click on “Obtain Your Statement of CE Credits for the 


first time. 


(2) Scroll down to Homestudy/OnDemand CE Credits 
and select the Quiz you want to take. 


(3) Log in using your username (your email address) and 
Password MPHA123 (case sensitive). Please change 


your password after logging in to protect your privacy. 


Mozaffarian D, Geelen A, Brouwer IA, et al. Effect 
of fish oil on heart rate in humans: a meta-anal- 
ysis of randomized control trials. Circulation. 
2005;112(13):1945. 


saturated fatty acids and inflammatory mediator 
production. Am J Clin Nutr. 2000;71(1 Suppl):343S. 


Stone NJ, Robinson J, Lichtenstein AH, Merz CNB, 
Blum CB, et al. 2013 ACC/AHA Guideline on 

the Treatment of Blood Cholesterol to Reduce 
Athersclerotic Cardiovascular Risk in Adults: A 
Report of the American College of Cardiology/ 
American Heart Association Task Force on Practice 
Guidelines. Circulation. 2013 Nov 12. Available 
from: http://airc.ahajournals.org. Accessed March 
15, 2014. 


_ Perk J, Backer G, Gohlke H, Graham |, Reiner, Z, et 


al. European Guidelines on cardiovascular disease 
prevention in clinical practice (version 2012). Eur 
Heart J 2012 May 3 Available from http://eurheart). 
oxfordjournals.org. Accessed March 15, 2014. 


Standards of Medical Care in Diabetes — 2013. 
Diabetes Care 2013 January;36(S)1 S11-S66. 


Jellinger PS, Mehta AE, Handelsman Y, Shepherd 
MD. American Association of Clinical Endocrinolo- 
gists’ Guidelines for Management of Dyslipidemia 
and Prevention of Atherosclerosis. Endocrine 
Practice. 2012 Mar/Apr Available from: http://www. 
aace.com/publications/guidelines. Accessed March 
15, 2014. 


. Bang HO, Dyerberg J. Lipid Metabolism and 


Ischemic Heart Disease in Greenland Eskimos. Adv 
Nutr Re. New York Plenum Press, 1980(3):1-22. 


Hopper L, Ness A, Higgins JP Moore T, Ebrahim 
S. GISSI-Prevenzione Trial. Lancet 1999 Oct 
30;354(9189):1557. 


Ie, 


20. 


iN 


22 


(4) Click the Test link to take the quiz. 


Note: If this is not the first time you are signing in, just 
scroll down to Homestudy/OnDemand CE Credits and 
select the quiz you want to take. 


. Tavazzi L, Maggioni AP. Marchioli R, et al. Effect of 


n-3 polyunsaturated fatty acids in patients with 
chronic heart failure (the GISSI-HF trial): a random- 
ized, double-blind, placebo-controlled trial. Lancent 
2008 Oct 4;372(9645):1223-30. 


Yokoyama M, Origasa H, Matsuzaki M, et al. Effects 
of eicosapentaenoic acid on major coronary 
events in hypercholesterolaemic patients VELIS): a 
randomized open-label, blinded endpoint analysis. 
Lancet. 2007 Mar 31;369(9567):1090-8. 


The ORIGIN Trial Investigators. n-3 fatty acids and 
cardiovascular outcomes in patients with dysglyce- 
mia. N Engl J Med. 2012;367:309-318. 


The Risk and Prevention Study Collaborative Group. 
n-3 fatty acids in patients with multiple cardiovas- 
cular risk factors. N Engl J Med 2013; 368:1800- 
1808 


Kromhout D, Giltay EJ, Geleijnse JM. n-3 fatty acids 
and cardiovascular events after myocardial infarc- 
tion. N Eng J Med 2010; 363;2015-2026. 


MARYLANDPHARMACIST.ORG fi 25 


On the Hill for Rximpact Day 


Courtney Lanehart, PharmD Candidate 2017, Notre Dame of Maryland University School of Pharmacy 


In my second month of my first year 
in pharmacy school at Notre Dame 

of Maryland University School of 
Pharmacy (NDMU SOP), | received an 
email about an initiative to advocate 
for pharmacy at the national level with 
the National Association of Chain Drug 
Stores (NACDS). NACDS was accepting 
applications from students across 

the country to participate in their 6th 
annual Rxlmpact Day on Capitol Hill 

in Washington, D.C. in March 2014. 

| jumped at this opportunity and 
submitted my CV and application, 

just barely making the cut-off date. 

A few weeks later | was informed 

by Ifeoma Ibe, another student from 
NDMU SOP that she and | were 
chosen to participate! | was ecstatic 
about being selected, but | definitely 
underestimated how powerful this 
event would be. 


On March 12, 2014, the students 
chosen for Rxlmpact Day arrived at 
The Liaison Capitol Hill Hotel. We 
were welcomed into Rxlmpact “U” 
Academy, which was an informational 
session and workshop covering the 
history of Rxlmpact Day, leadership 
and advocacy skills, an insider's 

view of how Capitol Hill works, and 
discussions about legislation for which 
we would be advocating. We also 
participated in mock legislative visits 
with faculty mentors. This program 
was extremely beneficial in preparing 
the students for the day on the Hill. 

| applaud NACDS for the excellent 
Rxlmpact “U" Academy program. 


Early in the morning on March 

13, 2014, all of the Rxlmpact Day 
participants, over 400 from 40 states, 
gathered for breakfast and met with 
their teams. | belonged to Team 
Maryland comprised of myself & 8 
others, including Dr. Cynthia Boyle 
and Eric Barbye from University of 
Maryland Eastern Shore, community 
pharmacists with some of their interns 
and experiential students from the 
University of Maryland School of 


Pharmacy, and a pharmacist who 

is a senior manager of pharmacy 
purchasing. Team Maryland had five 
meetings at various congressional 
offices and two drop by appointments. 
We exclusively met with legislative 
assistants throughout the day, 
although we had a photo opportunity 
with Congressman Chris Van Hollen. 

| was exceptionally surprised at how 
well informed the legislative assistants 
were on the topics we presented. 

| was expecting to go into the 
appointments and have to explain 


We need committed 
pharmacists and 
Student pharmacists to 
continue advocating for 
our profession...this is 
our job...this is our life. 
Take pride and get what 
you want out of It. 


everything, but shockingly, we did not. 
| was also pleased to see that most of 
the assistants were receptive to our 
issues. Specifically Walter Gonzales, 
Health Legislative Assistant for 
Congressman Dutch Ruppersberger, 
was well-informed and encouraging. 
We hit a little resistance throughout 
the day, but Team Maryland worked 
together to answer questions and 
provide perspectives. 


Two days prior to Rximpact Day, H.R. 
4190 was introduced into the House 
of Representatives. This bill, if passed, 
would amend the Social Security 

Act of 1935 to list pharmacists as 
Medicare Part B providers. This was 
the hot topic of our visits! H.R. 4190 is 
such an important piece of legislation 
for the pharmacy profession and for 
patients. This could be a fundamental 


26 MB MARYLAND PHARMACIST | SUMMER 2014 


change to how pharmacists practice 
throughout the country. It was an 
honor to lobby for this legislation. We 
might have set-backs along the way 
to bill passage, but we'll stand up, 
brush off our white coats, and keep 
advocating. 


|am in my first year of pharmacy 
school and thus far | have had the 
chance to advocate at the state and 
national levels. | AM an advocate 

for the pharmacy profession, and | 
plan to keep it that way. However, we 
need more! Cultural anthropologist 
Margaret Mead once said, “Never 
doubt that a small group of thoughtful, 
committed citizens can change the 
world; indeed, it’s the only thing 

that ever has.” We need committed 
pharmacists and student pharmacists 
to continue advocating for our 
profession ... this is our job ... this 

is our life. Take pride and get what 
you want out of it. To the student 
pharmacists out there like me, listen 
up! This is our future on the line ... 
advocate for patients, other student 
pharmacists, and yourself. 


NACDS Rxilmpact Day planners 

do a wonderful job planning and 
organizing this successful event. | 
would like to thank NACDS for giving 
me this incredible opportunity, and | 
appreciate all the effort invested in the 
program for student pharmacists. As 
long as we continue advocating and 
don't lose sight of patients’ health, we 
can achieve provider status. 


For further reading, please access 
the following two articles from 
drugstorenews.com: 


http.//drugstorenews.com/article/ 
nacds-rximpact-shines-spotlight- 
pharmacists-increasing-role-delivery- 
healthcare-services 


http.//drugstorenews.com/article/ 
bipartisan-house-bill-seeks-designate- 
pharmacists-healthcare-providers- 
medicare 


VHP EXECUTIVE DIRECTOR'S 
MESSAGE 


One thing that has 
not changed Is 
that we are ONE 
Association for 
ALL pharmacists. 
Pick ONE way you 
can get involved in 
your Association 
this year. 


=a 7 


Today’s world is fast and exciting. 
There are a lot of changes and nothing 
seems to stay the same. Some 

think this is a great advancement 

in mankind and others struggle to 
keep up. The Maryland Pharmacists 
Association tries to blend the best of 
the new and the old. 


We have just come home from our 
132nd Annual Convention in Ocean 
City. Same location, different vibe. 
There were some changes and some 
traditional events. Topics for CE were 
on trend with the conversations in the 
pharmacy profession, as well as the 
tried and true programs. New faces 
joined us and many familiar faces 
were still around. We had new and 
exciting fundraisers for the MPhA 
Foundation and raised $1,400! Your 
new Board of Trustees were installed, 
however, your President and Chairman 
of the Board remained the same. A 
Survey will go out to those who did 
and did not attend so that we can 

get feedback on your experience. We 
encourage you to return it quickly! 


The office has seen some changes 
this year. Our Member Benefits 
Coordinator, Shawn Collins, and 
Marketing Coordinator, Kelly Fisher, 
are new additions to our staff. Our 
Office Manager, Elsie Prince, remains 
in her position still after 18 years of 
service to our Association. We are 

in the process of finding the right 
person for the job as our Executive 
Director. Howard Schiff served this 
Association well for many years. 
Peggy Funk showed us how marketing 
and communication can make our 
organization stronger. Kristen Fink 

is graciously chairing our Selection 
Committee and the Committee is 

a diverse collection of members 

in varying areas of pharmacy practice. 
The Committee is working hard 

and we look forward to welcoming 
their choice. 


During Convention, the Board of 
Trustees voted to move forward with 
the purchase of a building. This will 
provide us with permanent space 
for our museum, office staff, and 
meeting space. Many years ago, our 
leadership Set up a great opportunity 
for the Association and your current 
leadership is doing everything it can 
to keep the strong tradition of fiscal 
responsibility and foresight. 


Lots of changes and lots of things 

that stay the same. One thing that 

has not changed is that we are ONE 
Association for ALL pharmacists. Pick 
ONE way you can get involved in 

your Association this year. Will it be a 
committee, or a new event, or asking a 
colleague to join as anew member? 


| look forward to hearing what your 
ONE new activity will be this year 
because we are ... 


Stronger by Association — 


Lee 


Dixie Leikach, RPh, MBA, FACA 
Interim Executive Director 
Dixie.Leikach@mdpha.com 


MARYLANDPHARMACIST.ORG 27 


UNIVERSITY of MARYLAND 


EASTERN SHORE 
school of Pharmacy 


Chi 


mnt = 


whe nT 


Whether it is in a hospital or a school, at an eldercare UMES HAS THE ONLY 3-YEAR 


CONCENTRATED DOCTOR OF 


facility or a pharmacy, in the military, near or far, 
PHARMACY PROGRAM IN MARYLAND. 


UMES pharmacy graduates are integral to our Nation’s 
commitment to provide every American with quality We are proud to support 


health care. Maryland Pharmacy! 


Visit us at: www.umes.edu/pharmacy 


MID-YEAR MEETING PREVENTING ADVERSE UNDERSTANDING THE 
Highlights ¢e MPhA/MD-ASCP/ COVER PHOTO 


§ DRUG EVENTS | HIGH-TOUCH MODEL 
MSHP/MPhS MARYLAND PHARMACISTS IN Defining the Problem Getting Acquainted with 
EMERGENCY PREPAREDN ESS: and Promoting Action Specialty Pharmacy 


A BRIEF HISTORY 


Board of Pharmacy Emergency 
Preparedness Taskforce 


ii “You cannot predict 
where evil will raise its head, 
but you can be 
PF ELE Tor it: 


al. Russel Pearce: idee = , 


» ¥% ts : , a < 
oo, hoo ae 


tS 


MARYLAND PHARMACISTS ASSOCIATION JOURNAL | SPRING 2014 


79 | PRESIDENT'S PAD 


c Go. 
‘ JA ; 


b SGN" % 


The profession 
needs you; take 
the plunge, and 
help us out. 


aay fe 


Pharmacists testify 

in Annapolis on the 
PBM-Pharmacy 
Contracts-Payments bill, 
SB952. 


2 MX MARYLAND PHARMACIST | 


Dear MPhA members, 


This past winter my knowledge and 
involvement regarding the legislative 
process grew immensely. For starters, | 
became more involved in the Maryland 
Pharmacy Coalition. | volunteered to 
assist in writing position statements 
and to be on the team that developed 
the leave behind for Legislative Day. 

| was given many opportunities to 
provide testimony for a number 

of bills involving pharmacy. 


Through my involvement this year | was 
able to learn more about the overall 
process, the politics, and what occurs 
during the Legislative Session. At times It 
was overwhelming, but | had a number of 
pharmacists and resources available to 
assist me. 


Most importantly, | learned about 

how critical it is for pharmacists, 
technicians, and students to represent 
the pharmacy profession. If you have 
taken the trip to Annapolis in the past 
to testify on behalf of the pharmacy 
profession | would like to thank you. 
You are the reason | am able to provide 
immunizations and have a Drug Therapy 
Management Protocol in place. 


Until this year, | took the safe approach 
to the advocacy role; | was silent. 
Advocacy to me felt like diving into 
murky water, uncomfortable. | know 
many pharmacists feel the same way. 
After this year, | learned the silent 
approach does not work in Legislation. 
Do not let your insecurities get in the way 
of being involved in speaking up for the 
profession. The profession needs you; 
take the plunge, and help us out. 


When you renew your membership for 
2015, consider checking the “Yes” box 
next to “Interesting in Testifying during 
the Legislative Session.” 

| know | still have lots to learn about the 
process. This year was a great experience 
and | am committed to staying involved 
in advocacy in the future. 


Warm regards, 


O hristinate.- (Dod 


Christine Lee-Wilson, PharmD 
President 


Ca are 


MARYLAND PHARMACIST 


FEATURES 


SPRING 2014 


Maryland Pharmacists in Emergency Preparedness: 


A Brief History 


1 @ Rx and the Law: Discovery 101 


14 
20 


Preventing Adverse Drug Events: Defining the Problem 


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AdvoCaring 


DEPARTMENTS 


2 
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President's Pad 
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Wolfe & Fiedler, P.A. 
Rite Aid® Pharmacy 
McKesson 
Pharmacists Mutual 
Buy-Sell-A-Pharmacy 
Cardinal Health 


University of Maryland 
Eastern Shore 


4 
S 
Noniyi2°” 


MARYLAND PHARMACISTS ASSOCIATION 


€sT, 1982 


MPhA OFFICERS 2013-2014 

Brian Hose, PharmD, Chairman of the Board 

Christine Lee-Wilson, PharmD, President 

Dixie Leikach, RPh, Vice President 

Matthew Shimoda, PharmD, Treasurer 

Frank Palumbo, BSPharm, MS, PhD, JD, Honorary President 


HOUSE OFFICERS 
Chai Wang, PharmD, Speaker 
G. Lawrence Hogue, BSPharm, PD, Vice Speaker 


MPhA TRUSTEES 

Doug Campbell, RPh, 2014 

Nicole Culhane, PharmD, 2016 

Kristen Fink, PharmD, BCPS, CDE, 2015 

Mark Lapouraille, RPh, 2016 

Hoai-An Truong, PharmD, MPH, 2014 

Wayne VanWie, RPh, 2015 

Jane Kim, ASP Student President, University of Maryland 


EX-OFFICIO MEMBERS 
Dennis M. Killian, PharmD, PhD, Interim Dean 

University of Maryland Eastern Shore School of Pharmacy 
Natalie Eddington, PhD, Dean 

University of Maryland School of Pharmacy 
Anne Lin, PharmD, Dean 

Notre Dame of Maryland University School of Pharmacy 
David Jones, RPh, FASCP, MD-ASCP Representative 
Brian Grover, PharmD, MSHP Representative 


CONTRIBUTORS 
Peggy Funk, Maryland Pharmacist Editor 
Interim Executive Director 


PEER REVIEWERS 

Chris Charles, PharmD 

G. Lawrence Hogue, BSPharm, PD 
Edward Knapp, PharmD Candidate, 2014 
Jamie Nguyen, PharmD Candidate, 2016 
Frank Nice, RPh, DPA, CPHP 

Cynthia Thompson, PharmD 


Special thanks to the following contributors: 
Elsie Prince, Office Manager 

MPhA Communications Committee, chaired by Chai Wang 
Kelly Fisher, Marketing Coordinator 

Graphtech, Advertising Sales and Design 


We welcome your feedback and ideas for future articles 

for Maryland Pharmacist. Send your suggestions to Peggy 
Funk, Maryland Pharmacists Association, 1800 Washington 
Blvd., Ste. 333, Baltimore, MD 21230, or email peggy.funk@ 
mdpha.com, or call 410.727.0746 


A Brief History 


The Maryland Board of Pharmacy 
has been actively planning for 
emergency events since shortly after 
the 9/11/2001 attacks in New York 
and Washington D.C. The Maryland 
Board developed a Bioterrorism 
Committee to start planning to be able 
to respond to any event happening 
in Maryland and to help protect 

the health and welfare of Maryland 
citizens. With the help of Board’s 
Executive Director, LaVerne Naesea, 
and an ever changing series of State 
personnel assigned to work with 

the Board, that Committee became 
the first Bioterrorism Committee 
among the medical disciplines in 
the State. The Board's Bioterrorism 
Committee's initial project was to 
advertise for pharmacist volunteers 
from all areas of the State. The 
Board sent requests by mail and 
made phone calls and in short order 
had well over 100 volunteers. 


The early emphasis was on treatment 
for anthrax or other deadly toxins 
and several practice exercises 

were held. One in particular was 

a full scale clinic set-up in which 
pharmacists dispensed ‘medicine’ 
and gave advice to people who had 
‘found themselves in disaster areas.’ 
Pharmacists were designated as 
‘leads’ for each area and several 
went to, Baltimore City and the 
various County Health Departments 
to explain how the Committee could 
help with their local planning. 


Then came Hurricane Katrina in 2005. 
Just a few hours after the first phone 


4 MM MARYLAND PHARMACIST | 


By: G. Lawrence Hogue, PD 
Donald Taylor, RPh 
Arnold Honkofsky, PD 


“You cannot 
predict 
where evil 
will raise its 
head, but 
you can be 
prepared 
[Or ite 


— Russell Pearce 


call, the Board asked for volunteers 
to go to the Louisiana area, in 
particular to Jefferson Parish where 
the Maryland National Guard, along 
with well over 100 medical discipline 
volunteers (who had been sworn 

in as Guardsmen for the two week 
anticipated duration of the mission) 


took control of the county. The people 
who did not get out in time had no 
electricity other than emergency 
generators, NO open stores, no land 
line telephones, essentially no way 

to exist except through the services 
provided by the volunteers. These 
services included medical services 
and supplies, food, drinkable water, 
and ice to help them in the 90+ 
degree heat and high humidity. The 
Board's volunteers were billeted in an 
abandoned hospital, which was rank 
from the flood waters that had gone 
through. It took over a week to make 
it fully habitable. In the meantime, 

Six Clinics were set up in the county 
and a pharmacist was assigned 

to each group when there were 
enough (the Board sent a total of 13 
Maryland volunteer pharmacists over 
approximately 2 months). They helped 
physicians decide what medicine to 
dispense since the medical supplies 
were severely limited, cleaned up 
areas of the hospital including the 
pharmacy, sorted the medications 
that the National Guard brought in 
from the samples in abandoned 
physician hospitals, and ordered drugs 
needed from the Federal Emergency 
Management Agency. The last function 
was extremely frustrating as supplies 
coming in were almost totally inept. 


That experience changed the focus 
of the Bioterrorism Committee 
dramatically. No longer was the Board 
only concerned with getting Cipro 

as protection against anthrax, but 
was now concerned with making 


sure that citizens of affected areas 
could get all types of urgently needed 
drugs when needed — drugs like anti- 
hypertensives and anti-diabetics. The 
Bioterrorism Committee morphed into 
the Board's Emergency Preparedness 
Task Force (EPTF). Up to this point, the 
Board had been solely responsible 
for recruiting and training pharmacy 
volunteers. The Department of Health 
and Mental Hygiene’s (DHMH) Office 
of Preparedness & Response (OP&R) 
Started the Maryland Professional 
Volunteer Corp (MPVC), and began 
recruiting volunteers from all of 

the medical disciplines. The OP&R 
director began attending the 

Board's EPTF monthly meetings, 
contributing to the EPTF’s knowledge 
of State plans and activities. 


OP&R requested an EPTF member to 
assist in the first Center for Disease 
Control and Prevention (CDC) meetings 
designed to locate a suitable facility 
for a State Receipt, Stage, Store (RSS) 
site. The RSS site is a CDC approved 
site designed to be utilized as the 
location to receive federal assets 
following an emergency event. The 
EPTF was also asked to participate in 
writing the first State Strategic National 
Stockpile (SNS) plan. That plan was 
required to meet specified federal 
requirements, and became the basis 
for all future emergency planning 

in Maryland. 


While the search for a suitable RSS 
site was progressing, a massive 
earthquake occurred in Haiti in 
2010. An EPTF pharmacist member 


Board of Pharmacy Emergency Preparedness Taskforce 


Bottom row, left to right: Dorothy Sheu, Stephanie Parsons*, Mel Rubin, Phil Cogan, Sajal 


Roy, Janet Seeds and Arnie Honkofsky 


Top row, left to right: Reid Zimmer, Kevin Jura*, Larry Hogue, Zack Sherr, Charmaine 


Rochester and Don Taylor 


* Department of Health and Mental Hygiene Operation Staff 


volunteered to go to Haiti to 

help wherever the need was the 
greatest. That member worked in 

an improvised Neonatal Intensive 
Care Unit. Conditions were hot and 
work areas certainly not sterile. “/t 
truly was “Pharmacy at the Improv“, 
or perhaps better described as 
“MacGyver Pharmacy.” Examples of 
this include making solutions and 
suspensions for oral use from tablets 
and capsules, making oral drugs from 
lV drugs, deciphering medication 
names labeled in different languages, 
creating D5%/0.45% “from scratch” 
without the luxury of available 
concentrated sodium chloride!” 

Help for the pharmacists and nurses 


RSS Pharmacy Volunteers — State Distribution Exercise 


often consisted of volunteer college 
Students trained on the fly. As was the 
case in Katrina, volunteers reported 
that the experience of “making a real 
difference in people's lives” made 
any problems encountered more 
than worthwhile. 


The massive devastation in Haiti 
highlighted the fact that just recruiting 
professional volunteers was not 
Sufficient for large scale events, 

and the MPVC was changed to MD 
Responds, which includes volunteers 
from all personnel arenas — not just 
medical personnel. The Director of 
MD Responds continues to attend the 
Board’s EPTF monthly meetings and 
encourages pharmacy participation at 
the State planning levels. 


Once a Maryland RSS site was 
approved, an OP&R Committee 

was formed to begin planning for 
developing procedures for future 
receipt and storing of purchased 
medical assets, in addition to any 
assets received from the federal 
stockpiles. An EPTF pharmacist 
member was recruited to serve as a 
member of the newly formed State 
RSS Task Force. That member currently 
attends RSS Committee meetings, 
and the EPTF is actively involved in 
revisions to the State SNS plan. The 
latest rewrite of the State SNS plan 
has updated that plan to include an 


MARYLANDPHARMACIST.ORG & 5 


Treatment 
Tratamiento 


all hazards approach to emergency 
preparedness. In coordination with 
the federal plan, the new State 

plan in now referred to as the 
Emergency Medical Countermeasure 
Dispensing and Distribution Plan 
(eMCM). Pharmacy has defined 

RSS roles written into the eMCM 
plan: (1) overseeing all Controlled 
Dangerous Substance functions; (2) 
dispensing prophylactic medications 
to RSS personnel and their families 
(if required); (3) overseeing any RSS 
repackaging operations; (4) quality 
assurance of all outgoing orders prior 
to loading onto delivery vehicles; 

and (5) serving as a resource for 
medication related questions/issues. 


The EPTF has been recognized by 
OP&R, DHMH and CDC as being an 
integral part of emergency planning 

in Maryland. The EPTF has become 

a front line resource for State 
mediation related questions, as well as 
Storage and distribution issues. Core 


6 9 MARYLAND PHARMACIST | 


t 
Treatmen 
Tratamiento 


members of the EPTF are required to 
take mandatory training courses as 
required by CDC. Currently, the EPTF 
still meets each month, participates 
in RSS planning, updates the State’s 
emergency plans and, participates in 
State emergency preparedness drills 
and exercises. One member of the 
EPTF has been presenting emergency 
preparedness lectures to student 
pharmacists at all three pharmacy 
schools in Maryland. These lectures 
highlight pharmacy roles in Maryland 
emergency preparedness planning 
and training. 


Another member introduced the 
innovative concept of conducting 
Point of Dispensing (POD)* exercises 
for student pharmacists. The inaugural 
drill, the first ever conducted at a 
Maryland school of pharmacy and 
possibly the nation, was conducted 

at the University of Maryland Eastern 
Shore School of Pharmacy (UMES) in 
June 2013. Another drill was held in 


Photo 1 
RSS Pharmacy Volunteers — 
State Distribution Exercise 


Photo 2 
Mel Rubin at Jefferson Parish helping out 
after Hurricane Katrina 


Photo 3 
UMES Student POD Exercise 


September at UMES and was followed 
with an exercise at Notre Dame of 
Maryland University in November. 
These exercises serve as introductory 
emergency preparedness courses to 
pharmacy students about “Pharmacy 
Roles in Emergency Preparedness in 
Maryland.” Students get to observe 

a sample POD setup and participate 
by manning 3 different POD stations 
as well as play patients who are 
picking up medications for their 
entire families. Stations manned by 
the students include registration, 
medication triage, and dispensing. 
Students that have participated 

in a past POD exercise are then 
encouraged to participate in future 
exercises as facilitators helping the 
next year’s pharmacy students during 
their POD exercise. 


The EPTF remains active in 
emergency preparedness planning 
and exercises in all areas of the State. 
During the September 2013 State 


Distribution Exercise, the EPTF and pharmacy volunteers 
were recognized for their participation. In the summary for 
that exercise, the pharmacy volunteers were singled out as ° 
a “key group responsible for the success of RSS operations. olfe & Fiedler, PA. 
Several strengths were identified during their evaluation Certified Public Accountants 
during exercise operations. Especially impressive was the 
supportive role played by the BOP Executive Committee, BOP 
Commissioners and the Board's Emergency Preparedness 
Task Force. This was the first time such a supportive and 
integrated role by a Maryland professional board has been 
documented and recognized. Certainly, this involvement and ; i 
participation should be encouraged and continued.” The EPTF CPA Support for Individuals and Businesses 
ye also ae ‘i ee ela miegtte at with 2 Locations 1n 

altimore City in drills and exercises held at the local levels. i Er 
The Task Force does have student pharmacist representation Catonsville and Eldersburg: 
and encourages any interested pharmacist, student, or 
pharmacy technician to attend the monthly meetings. 


Are YOU prepared? Do YOU have an emergency preparedness , ; 
plan? Would YOU consider donating some of your time to be Business and Personal Tax Planning 


an EPTF member? If so, contact Janet Seeds at janet.seeds@ Business Accounting and Auditi 
maryland.gov. ier 
and everything in between. 


Change is inevitable...Progress is optional. 


Tax Preparation 


* PODs are designated locations in a community such as 
schools, fire halls, hospitals, etc. where residents would www. WolfeandHedler.com 
be directed to go to receive medications and supplies in a 
declared emergency. 


We take the success of our pharmacists personally. 
Whether you’re a current student looking for an introduction to the field 
or a Pharmacist wanting to advance your career, let Rite Aid help you realize your goals. 


_AID 


PHARMACY 


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Please visit our career site at www.RiteAid.com/careers 


Rite Aid is an Equal Opportunity Employer 


MSKESSON 


with 
McKesson 


ATT O HOHE H THESE HEHEHE EEE EEF EES EH EEE HEE EEEEEES 
+ 


Growth Starts with a Strong Foundation 


For 178 years, McKesson has been delivering to independent 
pharmacies — making sure you have the right product, at the 
right time, at the right price. 


McKesson is proud 

: to support the Maryland 
Today, we are partnering with pharmacy owners, like you, : Pharmacists Association. 
to help you grow revenues, maximize reimbursements and 

Strengthen patient relationships. 


. 
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Call 866.329.0113 or visit 
www.growwithmckesson.com 
to learn how we can help you flourish. 


Came to our newest members! 


Eva Alm Seema Kazmi Keith Pfaff 
Hector Ayu Kaela Keluskar Joan Phillips 
Merlyn Crandon Dennis Killian Tracy Rhodes 
Linn Galligan Katherine Lodowski Kelly Slear 
Blaine Houst Juliana Mbanusi Michele Straus 
Calista Jones Sherry Moore Tahani Wanis 


Mike Jones Duyen Nguyen 


Stay Connected! 
MarylandPharmacist.org 


veel MARYLAND PHARMACISTS ASSOCIATION 


MPhA 132"? ANNUAL CONVENTION 
Friday, June 13 — Monday, June 16, 2014 


WAVIGATING 


Register online at marylandpharmacist.org 


MARYLANDPHARMACIST.ORG fi 9 


This series, Pharmacy and the Law, is presented 


by Pharmacists Mutual Insurance Company 
and your State Pharmacy Association through 
Pharmacy Marketing Group, Inc., a Company 
dedicated to providing quality products and 


services to the pharmacy community. 


10 MARYLAND PHARMACIST | 


By Don R McGuire Jr., RPh, JD 


DISCOVERY 101_ 


Ask anyone who works in the claims department 
at an insurance company and they will tell you that 
the Discovery phase of litigation is the most time- 
consuming and expensive part of the process. But 
if you don’t work in the claims department or a law 
firm, could you readily explain what Discovery is 
and why it is so costly? 


Discovery is defined by Rules 26 to 37 of the 
Federal Rules of Civil Procedure’. Discovery is a 
process where opposing sides in the litigation 

Share information about the case with each other. 
This process is mandatory, although compliance 
with the rules is generally self-enforced by the 
parties. This sharing of information takes many 
forms and helps each side to evaluate the strengths 
and weaknesses of their case prior to trial. These 
forms include: 


1. Depositions by Oral Examination 
2. Depositions by Written Questions 
3. Interrogatories to Parties 


4. Producing Documents, Electronically Stored 
Information, and Tangible Things, or Entering 
onto Land, for Inspection and Other Purposes 


5. Physical and Mental Examinations 
6. Requests for Admissions. 


Depositions, whether written or oral, are one of the 
largest cost drivers in the Discovery process. Little use of 
Depositions by Written Questions is seen in most cases, 
So | will concentrate on Deposition by Oral Examination. 
The main reason that this exchange consumes so much 
time and money is that virtually anyone connected 

with the case can be deposed. The parties, employees 
of the parties, fact witnesses, and 

expert witnesses can all be deposed. 
Depending on the complexity of the 
case, the deposition can be a half day, 
whole day, or potentially even multiple 
days. Coordinating witnesses’, parties’, 
and attorneys’ schedules can be a 
nightmare. This is multiplied in multiple 
defendant cases or class action cases. 
Depositions are important because 

they give a preview of what a witness is 
going to say on the stand at trial. Witness 
testimony is crucial to evaluating a case. 
Preparation for a deposition, taking the 
deposition, and analysis of the answers 
are time consuming for your attorney. 

lf the number of depositions are large, 
Discovery is well on its way to being the 
most expensive part of litigation. 
Interrogatories are written questions that 
can only be submitted to the opposing 
party. They cannot be used to gain 
information from witnesses or other non- 
parties. There is a limit to the number of 
Interrogatories that can be served on the 
opposition. Many times Interrogatories 
are used to gather background facts such 
as date of birth, address, work history, arrest records, etc. 
As with deposition questions, it is permissible to object to 
questions, but the objecting party must have a good faith 
basis to object beyond just not wanting to answer. 


Producing Documents, Electronically Stored Information, 
and Tangible Things, or Entering onto Land, for Inspection 
and Other Purposes is comprised of 2 parts. The inspection 
of land and/or buildings occurs when relevant, but the 
bigger issue here is documents. In the not too distant past, 
this rule dealt almost exclusively with documents. Not so 
today. This rule encompasses not only paper documents, 
but e-documents, e-mail, spreadsheets, photos, drawings, 
and almost anything else that you can imagine. Recent 
changes to the rule require that electronic documents 

be produced electronically to preserve the metadata. 
Metadata and its implications are a topic of their own, but 
be aware that metadata can have a dramatic impact on the 
evidentiary value of the documents themselves. When the 


Discovery is a process 
where opposing sides 
in the litigation share 
information about 
the case with each 
other. It is one of the 
largest cost drivers in 


the Discovery process. 


case involves a complex issue and/or a long running issue, 
it doesn’t take too long these requests for production to 
take on a life (and an expense) of their own. 


Parties may also request that the opposing party undergo a 
physical or mental examination. This is not automatic. The 
request must be approved by the court. The examination 
must be relevant to some issue in the case, so this cannot 
be requested without reason. This is usually used in 
Situations where the party wants an independent opinion 
on, or verification of, the opposing party’s condition. 


The last form of Discovery is the Request 
for Admission. This is a written request to 
the opposing party asking them to admit 
the truth of some facts, application of 
the law to the facts, or the genuineness 
of documents. As you might have 
guessed by now, the item in question 
must be relevant to the case at hand. 
The responding party must admit as 
requested, deny, or object to the request. 
Making an admission under this rule 
renders the issue decided and the issue 
is not debated at trial. This rule has the 
potential to shorten a trial. 


Discovery is self-governed by the 
parties and the rules provide deadlines 
for responding to the various forms of 
requests. Also, the parties cooperate 

to establish an overall schedule 

for Discovery to take place so that 
depositions, etc. are completed during 
a reasonable timeframe. Disputes about 
Discovery make their way in front of a 
judge. The judge can order the parties to 
participate in Discovery and can impose 
further sanctions, up to and including 
dismissal of the case, for failure to do So. 


Discovery is a very important part of the litigation process, 
but it can be very time-consuming and expensive to comply 
with. This is especially true for the pharmacist defendant 
who has to take time away to be deposed or spend valuable 
time searching for and organizing records. Your attorney 
does realize the impact that Discovery has on your life, but 
your attorney also knows the potential downside for failure 
to comply. 

This article discusses general principles of law and risk management. 

It is not intended as legal advice. Pharmacists should consult their own 
attorneys and insurance companies for specific advice. Pharmacists should 


be familiar with policies and procedures of their employers and insurance 
companies, and act accordingly. 


© Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, 
Risk Management & Compliance at Pharmacists Mutual Insurance 
Company. 


1 | will use the Federal rules for this article because they are consistent nationwide. Many states mimic them for their own rules, but you should make sure 


which approach your state takes. 


MARYLANDPHARMACIST.ORG § 11 


February 9, 2014 ¢ MPhA/MD-ASCP/MSHP/MPNS 


id-Year Meeting 


The 2014 Mid-Year Meeting, 
sponsored by PharmCon, was held for 
the first time at the Marriott Inn and 
Conference Center at the University 
of Maryland University College and 
gathered nearly 250 attendees. Thanks 
to the dedication and hard work from 
the four professional organizations 
(MPhA, MD-ASCP. MSHP, and MPhs) 
the event was a great success! 


Photo 1 
Jen Furst, Monica Healy 
and Danielle Keeley 


Photo 2 
Past Presidents, 
Joe DeMino and Joe Marrocco 


Photo 3 


Doug Campbell, 
James Ritchie and Walter Abel! 


12 MB MARYLAND PHARMACIST | 


The day kicked off with breakfast, 
followed by the morning continuing 
education sessions. Lunch followed 
and attendees had the chance to 
meet with the many exhibitors who 
came out to support this event. The 
afternoon sessions included four 
tracks and attendees had the option 


to choose which programs to attend. 


The day ended with only a little bit 


of snow and a Happy Hour hosted 

by the Professional Development 
Committee, which had a great turn 
out! A very special thanks to all those 
who attended, our Mid-Year speakers 
who gave educational and insightful 
presentations, and our student 
volunteers from all three Schools of 
Pharmacy. We look forward to seeing 
everyone again at next year’s meeting! 


Photo 4 
Some of our student volunteers: Sara Ly, 
Kelsey Tyson, Jane Kim and Pilar Davila 


Photo 5 
It was a full house for the morning sessions. 


Photo 6 
Gil Cohen, Matt Shimoda and Murhl Flowers 


Photo 7 

New Practitioner Network Members: Chris 
Charles, Joan Phillips, Deanna Tran, Kate 
Lodowski, Ilana Volansky, Ashley Moody, 
Jen Furst, Chai Wang 


Photo 8 
Christina Haddad and Sylvia Okrzesik 


MARYLANDPHARMACIST.ORG 


PREVENTING ADVERSE DRUG EVENTS: 


Defining 
the Problem and 


PROMOTING 
Action 


Eric Isley 

PharmD Candidate 2014 

Notre Dame of Maryland University 
School of Pharmacy 


Stephanie Walters 
PharmD Candidate 2014 
University of Maryland School of Pharmacy 


Jennifer Thomas, PharmD 


Adverse drug events (ADEs) are 
harmful and potentially preventable 
incidents that put patients at a 

~ higher risk for longer hospital stays, 
increased medical costs, and even 
death. It is estimated that ADEs and 
preventable ADEs (pADEs) can cost 

a single hospital up to $8.4 million 

a year.’ According to the Centers of 
Disease Control and Prevention (CDC), 
nearly 700,000 emergency room 
visits are caused by ADEs every year. 
In response to this risk to patients 
and the growing healthcare costs, 
the Office of Disease Prevention 

and Health Promotion (ODPHP) and 
its Federal Interagency Workgroups 
(FIlWs) drafted the National Action Plan 
for Adverse Drug Event Prevention.° 
This article focuses on summarizing 
the most recent hospital ADE data, 

as well as introducing the scope and 
domains of the Action Plan. 


The Healthcare Cost and Utilization 
Project (HCUP) monitors hospital 
ADEs. Between 2004 and 2008, 
hospital ADEs increased by 52% (from 
3.1% of all inpatient stays in 2004 to 
4.7% of all stays in 2008). However it 
is unclear if this increase was due to 
increased events, better reporting, or 
both.*® In 2011, HCUP assessed what 
proportion of hospitalized ADEs were 
present on admission (POA) versus 
those that were hospital acquired 
(HA). Thousands of hospitals from 

46 U.S. states participate in HCUP, 
however only 32 of those states 
report POA statistics. There were 20 
million hospital discharges assessed 
for ADE origin from hospital stays 

in 2011. There were three times as 
many POA ADEs (388 per 10,000 
hospital discharges) as HA (129 per 
10,000 hospital discharges) ADEs. In 
previous HCUP reports, the ADE rates 
were described as percentages; later 
reports transitioned to using events 
per 10,000 discharges as a standard 
format to increase comparability 

with other ADE monitoring systems. 
Of the total 2011 ADEs, the most 
common specific causes were C. 
difficile infection due to antibiotic use, 
antineoplastic drugs, and steroid use. 
Opioids and anticoagulants were also 
in the top ten causes of any ADE.° 


The HCUP Statistical Brief #164 
presented data for the four most 
common ADEs that occurred in 
hospital inpatient stays during 2011.7 It 
identified steroids, antibiotics, opiates 
and narcotics, and anticoagulants 

as the most common causes, 

with these four events occurring 

at a combined rate of 50.4 per 

10,000 discharges (19.7 steroids, 

12.9 antibiotics, 11.2 opiates and 
narcotics, 6.7 anticoagulants). Overall, 
the highest among the four were 
Steroids; however, when examining 
the rates across age groups, elderly 
(patients over 65) were more likely 

to experience an ADE associated 

with anticoagulant use. Patients over 
the age of 65 had the highest rates 

of any ADE compared with younger 
patients. Thus, as one may expect, the 
Medicare population had the highest 
overall rate of ADEs compared to 
patients who had private insurance 

or Medicaid. In fact, the Medicaid 
population had the lowest rates. 
Furthermore, urban teaching hospitals 
and private not-for-profit hospitals had 
the greatest ADE rates of the various 
hospital settings. This study identified 
medications that continue to be major 
causes of ADEs, as well as identifying 
which patients in various settings are 
at the greatest risk of experiencing an 
ADES 


ee pe 


According to the 
Centers of Disease 
Control and 
Prevention (CDC), 
nearly 700,000 
emergency room 
visits are caused by 
adverse drug events 
every year. 


ae! fi 


The National Action Plan for Adverse 
Drug Event Prevention draft document 
stated goal is to align the efforts of 
federal agencies to nationally reduce 
harm caused to patients by ADES 
with a focus on three medication 
categories: anticoagulants, agents 
for diabetes, and opioids. The aim 

of the Action Plan is to reduce the 
most common, clinically significant, 
preventable, and measurable ADEs.° 
Within its scope, the Action Plan 
addresses ADEs caused by high 
priority drug classes (anticoagulants, 
diabetic agents, and opioids) that 
occur in high-risk populations, such 
as the elderly. In order to reduce the 
harms caused by these medications, 
the Action Plan identifies and seeks 
to rectify gaps within federal agencies 
and to align their efforts in preventing 
ADEs. The Action Plan identified 

four areas of focus to reduce ADES: 
Surveillance, Prevention, Incentives 
and Oversight, and Investigation. The 
Surveillance goal is to coordinate 

the current federal surveillance 
resources that already exist in 

order to assess the rates of ADEs, 
focusing on ADEs with a known 
Significant public impact. Efforts 

are currently underway to refine 

the existing surveillance systems. 


Recommendations for prevention 
efforts include sharing of evidence 
based prevention tools among the 
interested federal agencies, as well as 
non-federal health care workers and 
consumers. An emphasis is placed on 
using root-cause analyses to identify 
latent determinants (those involving 
the patient or provider) of ADEs, as 
well as systemic and organizational 
factors that may contribute to ADES. 
The Department of Health and 
Human Services (DHHS) has various 
regulatory capabilities that involve 
oversight and incentives that can be 
leveraged to help prevent ADEs. DHHS 
has within its power the ability to use 
regulatory oversight of healthcare 
provision, various financial incentives, 
and Medicare/Medicaid initiatives. 
Examples include requiring hospitals 
to meet federal health and safety 
standards in order to participate in 
Medicare programs, as well as value- 


MARYLANDPHARMACIST.ORG (i 15 


based purchasing financial incentives 
where financial reimbursement is 
used to promote improvements in the 
quality of care. Lastly, the fourth area 
of focus, investigation, is intended to 
identify and assess gaps in the current 
knowledge of ADE prevention and to 
identify future research to address 
these needs. 


For over ten years anticoagulants 
continue to be one of the leading 
causes of hospitalized ADEs in 

the United States. The Action 

Plan has identified specific areas 

of improvement in the current 
Surveillance strategies, such as 
distinguishing between minor and 
major adverse bleeding events, 
improving access to electronic health 
records with pharmacy and lab data, 
and improving capturing ADEs in 
transitions of care, as well as within 
nursing homes and community- 
dwelling individuals. The evidence- 
based prevention tools for each of the 
different levels of care can be found 
within the Action Plan. Two examples 
are the Institute for Safe Medication 
Practices’ “Pathway for Medication 
Safety” toolkit for the hospital setting, 
and the National Quality Strategy 
Priorities’ (NQSP) “Opportunities 

for Advancing Anticoagulant ADE 
Prevention Strategies/Tools” for 
outpatient settings. Further incentives 
and oversight for anticoagulation ADE 
prevention are needed in each of 
these three care settings: specifically 
creating anticoagulation stewardship 
for inpatient settings, amending 
payment barriers to ensure the uptake 
of “high-quality ADE prevention 
Strategies” in the community, and 
fixing the barriers to interdisciplinary 
anticoagulation care in the nursing 
home. Through the utilization of these 
initiatives and further research, an 
improvement in safe anticoagulant 
use Is hopeful. 


With the large numbers of people 
living with diabetes and taking 
medications to treat it, hypoglycemia 
is an important ADE that occurs far 
too often and may be preventable. 
Comparing surveillance data for 
hypoglycemic events is difficult 
because definitions of hypoglycemia 
vary. The Action Plan suggests 


standardizing the definition and coding 
of hypoglycemic events when using 
national surveillance tools to improve 
consistent reporting. Using evidence- 
based recommendations from 
reputable organizations is warranted 
to help prevent hypoglycemic events. 
Examples include recommendations 
from the American Diabetes 
Association and the American 
Geriatric Society to individualize 

a patient’s glycemic goals based 

on life expectancy and comorbid 
conditions. More aggressive treatment 
to reach strict glycemic goals may not 
improve outcomes and puts patients 
at greater risk of hypoglycemic 
events. Various opportunities exist 

to reduce hypoglycemic events 
through proper use of incentives 

and oversight. These may include 
utilizing health information 
technology to alert providers of 

a patient's risk for hypoglycemia 

and various mechanisms for 
monitoring events that occur. The 
Action Plan also suggests various 
research opportunities in this area, 
such as examining how comorbid 
conditions may affect hypoglycemia, 
identifying rates of severe 
hypoglycemia in ambulatory care 
Settings, and describing the impact 
of quality measures on the rates of 
hypoglycemia. 


Opioid overdoses, both in normal 
care and abuse/misuse, are one 

of the leading preventable ADEs 
and are considered a major public 
health issue in America. Some of 
the advancements in surveillance 
Strategies recommended by the 
Action Plan include improving 
measures to better distinguish 
between opioid ADEs due to abuse 
versus normal care, promoting the 
increased use of prescription drug 
monitoring programs (PDMPs), and 
identifying the appropriate method 
of surveillance based on inpatient 
or outpatient settings. The NQSP’S 
tools and resources for the safe 
management of opioid therapy are 
described and organized by the 
following categories: self-care/health 
care provider knowledge, patients 
and family engagement, promoting 
best practices in the community, and 


16 MB MARYLAND PHARMACIST | SPRING 2014 


communication/care coordination. 
Further oversight is recommended 

in three different areas: quality 
measures based on value-based 
purchasing incentives, coverage 

of these services, and using payer 
data to identify the misuse/abuse of 
opioid medications. Areas for study 
for the prevention of opioid ADEs 
include: continued research to ensure 
the appropriateness/effectiveness 

of opioid prescribing guidelines, 
scrutiny of real-world practice versus 
recommended pain management, and 
examination of the clinical outcomes 
of PDMPS. 


Adverse drug events greatly impact 
Our patients’ quality of life and our 
nation’s healthcare cost. A concerted 
effort throughout all levels of care 

is needed to help prevent future 
adverse events, and the draft National 
Action Plan for Adverse Drug Event 
Prevention is an important resource in 
guiding this effort. 


REFERENCES 


1, Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, 
Sweitzer BJ, Leape LL. The costs of adverse drug events in hospitalized 
patients. Adverse Drug Events Prevention Study Group. JAMA. 

1997 Jan 22-29;277(4):307-11. 


2. Adults and Older Adults Adverse Drug Events. September 2012. Centers 
of Disease Control and Prevention, Atlanta, GA. Available at: http://www. 
cdc.gov/medicationsafety/adult_adversedrugevents.html 


3. U.S. Department of Health and Human Services, Office of Disease Preven- 
tion and Health Promotion. (2013). National Action Plan for Adverse 
Drug Event Prevention. Washington, DC: Author. 


4. Elixhauser, A. and Owens, P. (AHRQ). Adverse Drug Events in U.S. Hospi- 
tals, 2004. HCUP Statistical Brief #29. April 2007. Agency for Healthcare 
Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/ 
reports/statbriefs/sb29. pdf 


5. Lucado, J. (Social & Scientific Systems, Inc.), Paez, K. (Social & Scientific 
Systems, Inc.), and Elixhauser A. (AHRQ). Medication-Related Adverse 
Outcomes in U.S. Hospitals and Emergency Departments, 2008. HCUP 
Statistical Brief #109. April 2011. Agency for Healthcare Research and 
Quality, Rockville, MD. http://www.hcup-us.ahrg.gov/reports/statbriefs/ 
sb109.pdf. 


6. Weiss AJ (Truven Health Analytics), Elixhauser A (AHRQ), Bae J (Emory 
University), Encinosa W (AHRQ). Origin of Adverse Drug Events in U.S. 
Hospitals, 2011. HCUP Statistical Brief #158. July 2013. Agency for 
Healthcare Research and Quality, Rockville, MD. Available at: http:// 
www.hcup-us.ahrg.gov/reports/statbriefs/sb 158. pdf. 


7. Weiss AJ (Truven Health Analytics), Elixhauser A (AHRQ). Characteristics 
of Adverse Drug Events Originating During the Hospital Stay, 2011. 
HCUP Statistical Brief #164. October 2013. Agency for Healthcare 
Research and Quality, Rockville, MD. Available at: http://www.hcup-us. 
ahrg.gov/reports/statbriefs/sb 164. pdf. 


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a | CONTINUING EDUCATION 


UNDERSTANDING THE HIGH-TOUCH MODEL: 


Getting Acquainted wit 
-opecialty Pharmacy 


18 MARYLAND PHARMACIST 


DEFINING SPECIALTY PHARMACY 


Community pharmacy, in its broadest application, can be 
defined by the roles played by the community pharmacist 

in the healthcare system. According to the World Health 
Organization (WHO), community pharmacists have a breadth 
of responsibilities including, but not limited to:' 


e Processing and dispensing prescriptions in a timely manner; 
e Monitoring patients for safe drug utilization; 


¢ Clinical care of patients (i.e. integrating prescription history information, 
clarifying understanding of medications, medication counseling, etc.); 


e Extemporaneous preparation and small-scale manufacturing 
(compounding) of medications; 


e Responding to symptoms of minor ailments; 
e Informing healthcare professionals; and 
e General health promotion. 


In the United States, community pharmacies are often the most accessible 
point of care in the healthcare system. Furthermore, community 
pharmacies are widely considered to be the frontline of patient care in 
pharmacy practice. 


Specialty pharmacy has recently emerged as a subset of community 
pharmacy practice. According to the Specialty Pharmacy Association of 
America (SPAA), a specialty pharmacy is defined as “a unique category of 
professional pharmacy practice that incorporates a comprehensive and 
coordinated model of care for patients with chronic illnesses and complex 
medical conditions.”2 The specialty pharmacy model incorporates three 
elements of optimizing patient outcomes. The first element, commonly 
referred to as the high-touch service model, is designed to optimize 
therapy adherence.2 The term high-touch refers to the increased hands- 
on approach that specialty pharmacies use with their patients and care 
teams in disease management. This involves services to expedite the 
start of therapy, promote adherence, and manage patient dosing, drug 
effectiveness, and drug appropriateness.? The second element, patient 
satisfaction, is critical for the successful partnership between a specialty 
pharmacy and the patient.2 Satisfaction accrues from the efforts of 
specialty pharmacies to remove physical, logistical, and all other perceived 
barriers in a supportive partnership. The third element of specialty 
pharmacy is the specialty pharmacy standard of care.’ This incorporates 
clinical, operational, and administrative services for the patient. Clinical 
services for the patient includes removing barriers to medication 
administration such as pharmacist access around-the-clock and regular, 
personalized regimen reassessments.? Operational services for the patient 
includes removing barriers to medication access by maintaining product 
inventory and rigorous storage and shipping standards.’ Administrative 
services for the patient include removing financial barriers to medication 
procurement such as obtaining prior-authorizations and connecting 
patients with assistance programs. 


in general, specialty drugs can be classified in three sub-categories: 1) self- 
administered therapies, such as those for rheumatoid arthritis, psoriasis, 
and multiple sclerosis; 2) products injected or infused in an office or clinic 
setting including vaccines and treatments for various immune disorders; 
and 3) office- and clinic-administered chemotherapeutic agents. 


By: 

Michael Goldenhorn, PharmD Candidate 2016 
Rachel Smith, PharmD Candidate 2016 

P. Tim Rocafort, PharmD, BCACP 

University of Maryland School of Pharmacy 


LEARNING OBJECTIVES 


After reading this article, the learner 
should be able to: 


1. Evaluate the similarities and 
differences between a specialty and 
community pharmacy. 


2. Identify at least four types of diseases 
commonly managed by specialty 
pharmacies. 


3. Describe the advantages and 
disadvantages of specialty 
pharmacies. 


4. Outline a plan to incorporate basic 
specialty pharmacy services into a 
pharmacy practice setting. 


5.Explain the role of the pharmacist in a 
specialty pharmacy. 


KEY WORDS 


e specialty pharmacy 


¢ community pharmacy 
e pharmacy services 
e high-touch model 


e specialty medications 


MARYLANDPHARMACIST.ORG ff 19 


TABLE 1 


Common specialty medications corresponding to the disease for which they are indicated." 


Ripe ice eo homes 
Bevacizumab 
Imatinib Saquinavir 

Goserelin Lamivudine 

Tretinoin Ritonavir 

Erlotinib 


Leuprorelin 


Efavirenz 
Nelfinavir 


ra aS A PMNS UNREST 
: x Skeet tet er 
4 v | tel ‘ 
Rees aN id aN esol! é 
BD) Be aiev anal ccai th terri. an Rens ean to yt 


Etanercept 


Adalimumab 
Abatacept 
Golimumab 
Certolizumab Pegol 
Infliximab 


Sofosbuvir 
Simeprevir 
Peginterferon a-2a 
Peginterferon a-2b 
Ribavirin 

Telaprevir 


Mycophenolate’ 
Cyclosporine’ 
Somatropin' 
Interferon b-1a"" 
Glatiramer" 
Paricalcitol” 


“This category includes common specialty medications indicated to treat solid organ transplants’, growth hormone diseases’, multiple 
sclerosis", or endocrine disorders.” 


Examples of specialty medications 
are shown in Table 1. Recently, a 
guideline for defining a specialty drug 
has been adopted by one healthcare 
data company after ratification by 
numerous trade associations.’ The 
guideline suggests that a drug must 
have five of the following eight 
characteristics to be considered 
specialty: 


e Target and treat specific, mainly 
chronic, and often rare conditions; 


e Initiated by a specialist; 
* Typically not administered orally; 
¢ Requires special handling: 


e Involves unique distribution and 
administration channels; 


¢ Costly, ranging from $6,000-$750,000 
per year; 


e Usage warrants high degrees of 
patient management; or 


e Patients may require reimbursement 
assistance. 


A specialty pharmacy operates 
differently from a community 
pharmacy. A specialty pharmacy 
has the ability to devote more time 
to manage a patient's specialty 
medication regimen.? Prior- 
authorizations, financial resources, 
and prescription refills will all be 
addressed before they become 
burdensome for the patient.2 This is 


not always the case in community 
pharmacy practice. 


Despite the differences in operational 
Structure, community and specialty 
pharmacies share core values. 
Specialty pharmacies will often have 
24/7 access to pharmacists or nurses.” 
While not all community pharmacies 
hold these extended hours, 24-hour 
community pharmacies exist in many 
of North America’s major cities and 
Suburban areas. They offer access to 
pharmacists and trained staff outside 
of normal business hours; a significant 
benefit for patients who are unable to 
access the healthcare system during 
normal hours. Furthermore, the patient 
is the center of the pharmacy care 
model in both high-touch specialty 
pharmacies and community practice 
settings. Medication decisions in 

both areas ultimately aim to benefit 
the patient's safety and financial 
commitment. Services commonly 
offered by community and specialty 
pharmacies are compared in Table 2 
(See page 21.) 


UNDERSTANDING THE 
ADVANTAGES AND 
DISADVANTAGES OF 
SPECIALTY PHARMACY 


Specialty pharmacies offer care 
services that may not necessarily 


20 MB MARYLAND PHARMACIST | SPRING 2014 


be provided by general community 
pharmacies. There is increased 
coordination of care and expert 
advocacy for the patient with minimal 
inconvenience in a specialty pharmacy 
practice. Though supportive data is 
Sparse with this new area of practice, 
focusing on the patient produces 

a tailored approach to care that 
improves medication adherence.° A 
study evaluating clinical and economic 
outcomes of a transplant specialty 
pharmacy program for post-renal 
transplantation patients found that 

an advanced degree of intervention 
by a specialty pharmacy was 
associated with fewer readmissions, 
lower healthcare costs, and higher 
adherence rates.° In patients with 
many comorbidities and health 

that hangs in a delicate balance, 
adherence to their medications can 
be the difference between poor 
health outcomes and living a relatively 
healthy life.° 


The pharmacy also benefits from 
offering specialty medications and 
services. AS a business, specialty 
pharmacies thrive because specialty 
medications are profitable.° A 
successful pharmacy in this niche 
of practice has the potential to 
generate large revenue streams 
and profit margins from greater 
reimbursement per prescription. 
Pharmacists, technicians, and 


Supportive staff collaboration 

with the care team encourages 
efficiency, professionalism, and 
productivity. This Supports a more 
effective workflow in the pharmacy 
to optimize financial gains. As it 
currently stands, reimbursement 
rarely comes from services provided 
by specialty pharmacies. Nonetheless, 
by offering these services, patients 
that would benefit from this focused 
care are more likely to bring in their 
specialty prescriptions. More patients 
means generating more prescription 
reimbursement and when dispensing 


more expensive specialty medications, 


larger profits ensue in a specialty 
pharmacy practice. 


Specialty pharmacies often connect 
their patients with Supportive financial 
resources enabling patients to better 
afford their inherently expensive 
medications. However, there are 
times when medication costs may 
remain high for the patient, even after 
using discount services. Specialty 
medications also require special 


handling, administration, and often 
risk being wasted due to patients’ 
frequently changing drug regimens.® 
These additional considerations 
introduce increased potential for 
medication usage and safety errors. 


Specialty pharmacy is a potentially 
lucrative niche in the pharmacy 
industry. It is currently evolving but 
overall Supports efforts to expand the 
roles of pharmacists. These roles are 
discussed later in this article. 


IDENTIFYING A PATIENT ELIGIBLE 
FOR SPECIALTY PHARMACY 


All patients who use specialty 
medications may not benefit from 
services provided by specialty 
pharmacies. In addition, all patients 
who might benefit from specialty 
pharmacy services may not be 
using specialty medications. While 
there is no widely accepted system 
to recognize a patient who might 
benefit from specialty pharmacy 
services, it can be hypothesized 
that the first element for finding a 


TABLE 2 


potential candidate is to identify a 
patient managing a chronic disease 
State. This would make a patient likely 
to benefit from the services offered 
by the high-touch model. Diseases 
managed by specialty pharmacies are 
generally chronic conditions where 
disease control is the goal, rather than 
a cure.2 A pharmacist could assess 
the patient's ability to manage their 
condition by considering the following 
questions: 


e How stable are the patient's 
conditions? 


How appropriate is the patient's 
medication regimen? 


e How frequently are changes made 
to the regimen? 


How complex is the medication 
regimen? 

Is the patient using these 
medications appropriately? 


What is the cost and is the patient 
able to afford the medication 
regimen? 


This table identifies common pharmacy services and the settings where 


these services are consistently offered." 


Identifying and managing adverse drug reactions and side effects 


Tailoring a drug regimen to fit a patient’s lifestyle 


Scheduling one-on-one appointments between the pharmacist and patient to discuss medication therapy 


Proactively managing primary and secondary insurance to optimize coverage benefits 


Proactively managing formulary issues to optimize medication coverage 


Delivering medications to your home or work 


Providing weekly telephone calls or home visits after initiation of therapy 


Offering health status assessments (blood pressure screenings, lab testing, etc.) 


Providing therapeutic dose adjustment and therapeutic interchange alongside follow up calls after new or 
changed therapies (with collaborative protocol) 


Community : Specialty 


Certain pharmacy services are offered in both the community and specialty pharmacy practice setting. Others have been developed by and are 
more commonly offered by specialty pharmacies. 


MARYLANDPHARMACIST.ORG i 21 


Personal CaRxe Pharmacy 
recently identified an increase in 
their sales of immunosuppressant 
medications, specifically that of 
tacrolimus and mycophenolate 
mofetil. In addition, they discovered 
that a community hospital 

a few blocks away houses a 
comprehensive transplant center, 
where several of their new patients 
come from with these prescriptions. 
Personal CaRxe Pharmacy learned 
of the new specialty pharmacy 
model being implemented to 
address the challenges and 
opportunities for this patient 
population. In doing so, they aimed 
to utilize this model to ensure 
effective transitions of care and to 
enhance refill retention rate. They 
performed the following in order 
to establish themselves as a new 
specialty pharmacy: 


1. Collaborated with the 
community hospital's healthcare 
providers to assess their patient 
care needs after hospital 
discharge. 


2. Allocated resources for a 
pharmacist and technician 
who will solely work on filling, 
educating, and following up with 
patients about their specialty 
medications. 


3. Provided additional training for 
the pharmacist and technician 
assigned to this service to 
guarantee optimal patient care. 


4. Organized a group of individuals 
to manage the financial aspects 
of their medication acquisition 
(i.e. prior authorizations and 
insurance coverage information). 


5. Set-up an automatic refill 
reminder and medication 
delivery system to ensure 
patients always have their 
medications on-hand. 


22 MB MARYLAND PHARMACIST | 


Patients experiencing difficulty 
managing their chronic condition, 
who are non-adherent to therapy, are 
often good preliminary candidates 

for specialty pharmacy use. The term 
preliminary is used because continued 
patient satisfaction throughout the 
relationship is necessary for the 
partnership with a specialty pharmacy 
to succeed.? The pharmacist should 
clearly describe the experience that 

a specialty pharmacy will provide 

and gauge the patient's comfort 

in this transition of care. Since the 
high-touch model emphasizes a 

more patient-centered approach, 
perceptions of nonmedical factors 
(i.e. medication cost, convenience, 
and access) and their effect on overall 
care are accounted for to determine 
if Someone is a good candidate 

for specialty pharmacy use. Once 
established, a patient's satisfaction 
must be maintained throughout their 
experience for the partnership to 
flourish long-term. 


INCORPORATING SPECIALTY 
SERVICES INTO YOUR PRACTICE 


The business models of a successful 
specialty pharmacy and community 
pharmacy are similar in the sense that 
both pharmacies are playing a central 
role between drug procurement and 
drug dispensing/administration.’ Many 
community pharmacies offer services 
in common with specialty pharmacies 
such as medication delivery, patient 
monitoring, or offering health status 
assessments. Due to time constraints, 
potentially restricted pharmacy space, 
and high work volume that community 
pharmacies are known for, these 
services might not be executed as 
efficiently as in specialty pharmacies. 
With that in mind, proper planning will 
help incorporate specialty pharmacy 
services into any pharmacy practice, 
especially community settings. 


Before offering basic low- 

cost specialty services, the 
infrastructure of the pharmacy 
will need to be assessed.® A 
specialty pharmacy will need: 


e Ample cold storage; 
e Trained pharmacists and staff: 


e Data capturing and reporting 
systems; 


e Medical claims billing systems; 

¢ Coordination of infusion services; 
e Reimbursement support; and/or 
e 24-hour on-call pharmacist(s). 


a ff Li 


The business 
model of a 
successful 
specialty pharmacy 
requires that it 
plays a central 

role between drug 
procurement and 
drug dispensing/ 
administration. 


eo) Ee 


In addition, staff training is important. 
The level of pharmaceutical care 
needed in a specialty pharmacy 
practice goes beyond the traditional 
dispensing, counseling process, 

and the community pharmacy 
needs to ensure that its staff meets 
certain requirements.® Staff should 
be trained to proactively obtain 
medication refills from prescribers, 
clear prior authorizations through 
insurance companies, and eliminate 
insurance discrepancies for patients. 
Ultimately, this makes for a smoother 
Start because these are basic 
services offered by most specialty 
pharmacies. Pharmacy technicians 
may also obtain specialized training 
on common specialty drugs and 
handling/dispensing techniques.*? 
This allows management to 

assess the pharmacy’s current 
performance status and identify 


future efforts required from their 
team toward implementing a 
specialty pharmacy program. 


Additional specialized training for 
pharmacists may be necessary to 
establish a specialty program. While 
specialized pharmacist training 

is not required by law, numerous 
pharmacy associations encourage 
advanced specialized expertise by 
means of postgraduate residency, 
board certification, and/or specialty 
certification. The Specialty Pharmacy 
Certification Board (SPCB) has recently 
established a Certified Specialty 
Pharmacist (CSP) examination.’ A 
nationally certified development 
process was used to create this 
objective tool for identifying 
competent professionals within 
specialty pharmacy.’ 


Other considerations include store 
design, customer service, clinical 
programs, and marketing. Analysis 

of these components might identify 
barriers for program development and 
influence methods for implementing 
Specialty programs. Deciding which 
specializations and clinical programs 
the pharmacy wants to offer will help 
define a targeted patient population 
and engage marketing strategies. 
Implementing more complex specialty 
services (described in Table 2) could 
be considered as more patients 
requiring these services are involved. 


RECOGNIZING THE ROLE OF THE 
PHARMACIST IN A SPECIALTY 
PHARMACY 


In a specialty pharmacy, the 
pharmacist is responsible for 
integrating the clinical, administrative, 
and operational elements of specialty 
pharmacy into everyday practice.? 

By doing so, the high-touch specialty 
pharmacy service model can succeed 
in its aim to remove barriers to 
therapy adherence.’ 


While executing daily tasks in a 
specialty pharmacy is a team effort, 
the pharmacist is responsible for 
maintaining inventory of specialty 
medications, managing workflow, 
and remaining accessible to the 
patients. Given their accessibility, 
community pharmacists have the 


potential and responsibility to screen 
and recognize patients in need of 
specialty pharmacy services. 


The pharmacist in a specialty 
pharmacy is also responsible for 
integrating the level of communication 
on which the business model is 
balanced. Patient care becomes 
comprehensive when the pharmacy, 
providers, and payors communicate 
frequently, efficiently and effectively.’ 
The financial Success of a specialty 
pharmacy is rooted in this high- 
touch model, offering enhanced 
communication alongside attractive 
services designed to improve 
patient outcomes. These attractive 
services aim to increase patient flow, 
prescription volume, and ultimately 
revenue for the business. 


Integrated team decision making, 
efficient communication, and 
proactive financial management 
encompass the responsibilities of the 
pharmacist in promoting successful 
business practices and patient health. 


SUMMARY 


Specialty program development in a 
community pharmacy can pose many 
challenges. A particular challenge is 
that the pharmacist is responsible for 
assessing the infrastructure of the 
pharmacy prior to implementation—a 
Skill not typically taught in school. 
Determining the physical, financial, 
and personnel status of the pharmacy 
is pivotal to outlining a structured 
growth plan for developing a specialty 
program.® It is also the responsibility 
of the pharmacist to possess and 
maintain advanced licenses and/or 
certifications; and to encourage the 
same for technicians and supportive 
staff.e However, the pharmacist who 
can overcome those challenges 

and establish a specialty pharmacy 

is a Supportive source of expertise 

to many patients who can provide 
unparalleled high-quality service. 


ACKNOWLEDGEMENTS 


The authors extend their gratitude to 
Drs. Amy Nathanson, PharmD, AE-C, 
BCACP and Andrew Zullo, PharmD for 


offering their expertise and assistance. 


Food for thought: 


e How can a pharmacist prepare 
for the Certified Specialty 
Pharmacist (CSP) examination? 


¢ How does developing a specialty 
pharmacy impact its surrounding 
community and already 
established local pharmacies? 


e What start up costs should be 
accounted for in opening a 
specialty pharmacy? 


¢ How do pharmacist-prescriber 
relations influence services in a 
specialty pharmacy? 


e How might the high-touch model 
mature or change in years to 
come? How might it influence 
the whole industry in the future? 


REFERENCES 
Al: 


zh 


3. 


The role of the pharmacist in the health care system. World Health 
Organization; 1994. 59 p. Report No.: WHO/PHARM/94.569. 


Specialty Pharmacy — Definition. Florham Park (NJ): Specialty Pharmacy 
Association of America (US); 2013 Apr. 4 p. 


Sullivan SD. The promise of specialty pharmaceuticals: Are they worth the 
price? Journal of managed care pharmacy [Internet]. 2008; 
14(4 Suppl): $3. 


. Sauerwald, Pamela Leigh. Changing the Channel: Developments in U.S. 


Specialty Pharmaceutical Distribution. Pharmaceutical Commerce. 
2009; reprint. 


. Tschida. Managing specialty medication services through a specialty 


pharmacy program: The case of oral renal transplant immunosuppressant 
medications. Journal of managed care pharmacy [Internet]. 
2013;19(1):26-41. 


URAC Specialty Pharmacy White Paper: The Patient Centered Outgrowth 
of Specialty Pharmacy. Washington (DC): URAC (US); 2011. 12 p. 


Schwartz RN. NCCN task force report: Specialty pharmacy. Journal of the 
National Comprehensive Cancer Network [Internet]. 2010;8 Suppl 4:51. 


Steiber D, Erhardt DP. Specialty Pharmacy in Community Pharmacy: The 
Time Is Now - And How!. Alexandria (VA): National Association of Chain 
Drug Stores (US); 2006 Nov. 65 p. 


. Specialty Pharmacy Certification Board Recognizes First Wave of Certified 


Oo 


Specialty Pharmacists [Internet]. Alexandria (VA): National Association 
of Specialty Pharmacy (NASP); 2013 Nov 11 [cited 2014 Feb 5] 
Available from: http://www.nasprx.org/news/145595/Specialty- 
Pharmacy-Certification-Board-Recognizes-First-Wave-of-Certified- 
Specialty-Pharmacists.htm 


. OptumRx: Specialty Pharmacy Drug List [Internet]. California: 


OptumRx Inc.; 2013 [Cited 2014 Jan 21]. 8 p. Available from: 
https://www.optumrx.com/vgnpreview/HCP/Assets/PDF/ 
SpecialtyPharmacyDrugList.pdf 


. Rosenquist A. Medication therapy management services in community 


pharmacy: A pilot programme in HIV specialty pharmacies. 
J Eval Clin Pract [Internet]. 2010; 16(6): 1142. 


Continues on next page 


MARYLANDPHARMACIST.ORG if 23 


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(UAN) 0798-9999-14-013-H04-P your password after logging in to protect your privacy. 
The authors have no financial disclosures to report (4) Click the Test link to take the quiz. 


This program is Knowledge Based — acquiring factual 
knowledge that is based on evidence as accepted in the 
literature by the health care professionals. 


Note: If this is not the first time you are signing in, just 
scroll down to Homestudy/OnDemand CE Credits and 
select the quiz you want to take. 


Avoid diminishing the value of your pharmacy. 
Don’t leave money on the table when you 


transition the ownership of your business. 


CONSIDER THESE IMPORTANT ISSUES... ae 
1. Confidentiality is CRITICAL to maintaining business value. The more people who i 


know about a sale (employees, suppliers, customers), the less value it will ultimately 
have. Limit your conversations to trusted advisors, associates and family members. 


2. Connect to the largest group of QUALIFIED BUYERS to create the highest price, 
by leveraging the highest level of interest in your business. Limiting your buyer pool 
(e.g. ONLY your wholesaler's customers), limits your ability to sell and sale price. 


. DO NOT engage in conversations, information sharing or negotiations with ANY 
buyer without professional representation, particularly if contemplating a sale to a 
chain. Thirteen years of experience selling pharmacies has shown us time after time 
that direct engagement rarely—if ever—gets the independent owner the best price 

Your Local Specialist or the best deal. 

Jim Beatty, R.Ph. 


jimb@buy-sellapharmacy.com . 
Mey Nile chance >) Buy-Sellapharmacy.com Completely confidential! 


1-(877)-360-0095 www.buy-sellapharmacy.com 


ios) 


79> | STUDENT HIGHLIGHT 


Throughout my nearly 
four years at Notre 
Dame of Maryland 
University School of 
Pharmacy (NDMU-SOP) 
| have had the honor 
of participating in the 
AdvoCaring Program. 
The AdvoCaring 
Program is a novel 
community outreach 
project developed by 
two extraordinary pharmacists and NDMU-SOP faculty, Dr. 
Nicole Culhane and Dr. Michelle Fritsch. This community 
outreach project was implemented as a way to give back 
to Baltimore by assisting underserved populations in the 
Surrounding area. In the program, each student is assigned 
to an advising group that is paired up with a targeted, 
underserved population, which they will follow 

throughout their educational experience at 

NDMU. The program aims to give back to 

the community and to provide student 

pharmacists with a professional 
learning environment where they 
can practice their developing 
clinical skills to the benefit of the 
Baltimore community. 


My advising group was 
matched up with Gilchrist 
Hospice Care located in 
Towson, Maryland, the largest 
hospice care organization in 
the state. Gilchrist provides 


AavoCaring 


Christine Meehan 
PharmD Candidate 2014 
Notre Dame of Maryland University School of Pharmacy 


rE | 


Through the 
/ AdvoCaring project, 
/ |have a new understanding 
| of what a student pharmacist 
can accomplish and 
have developed an 
ever-growing compassion 


to provide families of 
Gilchrist home hospice 
patients with a full 
Thanksgiving meal. Eight 
student pharmacists, 
myself included, 
Shopped for the items 
generously donated 
by the Shoppers in the 
Perring Plaza Shopping 
Center the day before 
Thanksgiving. Each 
meal consisted of a turkey; a can of yams, vegetables, and 
cranberry sauce; a bag of dinner rolls; and a pumpkin pie for 
dessert. We decorated cardboard boxes and wrapped up 
each meal to create a special gift for each family selected 
by the Gilchrist staff. Participating in the Adopt A Family 
for Thanksgiving event was a moving experience. Helping 
families that were unable to purchase a Thanksgiving 
meal—whether for financial reasons or the 
inability to leave their loved one at home 
for a period of time—was a humbling 
experience that has sparked my 
desire to continue to assist people 
in need. 


| sincerely believe that the 
initiation of the AdvoCaring 
project has touched many 
lives, including mine. | have 
had the opportunity to 
witness how donating a 
couple of hours to hospice 

each semester can have a 


inpatient as well as home-based ; positive impact on many lives. 
quality care to thousands of for helping people It was remarkable to learn that 
patients and their families in the IN need. a “Pharmacy Call-List,” which 


State of Maryland. Hospice care is 

defined as supportive or palliative care 

for individuals diagnosed with incurable 

illnesses. We were afforded the opportunity to 

perform annual needs assessments; promote health 

and wellness through blood pressure screenings, diabetes 
education, and medication safety at wellness fairs hosted 
for Gilchrist staff and patient's families; organize a flu 
clinic; and participate in fundraising events for Gilchrist's 
sister hospice center in Tanzania. The preceding list is not 
exhaustive; rather, it is a representative sample of the type 
of rewarding work students are able to experience in the 
AdvoCaring program. 


One of my most memorable and rewarding experiences 
with the program was participating in the Adopt A Family for 
Thanksgiving in 2011. We were fortunate enough to get five 
Thanksgiving meals donated from Shoppers grocery store 


A | 


consisted of compiling a database 
of pharmacies in areas where home 
hospice patients lived who carried comfort 
medications, saved Gilchrist approximately 
four thousand dollars. | had no idea that as a student 
pharmacist | could make such a big impact. Knowing that 
| participated in giving five families, suffering through the 
impending loss of a loved one, a wonderful Thanksgiving 
meal brings a smile to my face. Through the AdvoCaring 
project, | have a new understanding of what a student 
pharmacist can accomplish and have developed an 
ever-growing compassion for helping people in need. My 
experiences with this project will stay with me forever and 
have already begun to impact my clinical decisions as a 
future pharmacist. | am eternally grateful for this experience 
and encourage other student pharmacists to develop 
connections with at-need populations in their area. 


MARYLANDPHARMACIST.ORG ff 25 


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MEMBER MENTIONS 


— 
YO 


Members in the News 


On January 27, 2014, Peggy 
Funk, Interim Executive 
Director, accepted the Maryland 
Pharmacists Association's 2013 
Marketing Excellence Award 

for Best Non-Profit Campaign 
presented by the American 
Marketing Association Baltimore. 
The Marketing Excellence 

Award recognizes outstanding 
and effective marketing that 
demonstrates a campaign's 
success with measurable 

results in the Greater Baltimore region. This award focused 
on MPhA‘s integrated marketing and communications 
campaign that included the promotion and execution of 
all of the Association’s initiatives surrounding membership 


recruitment and retention, social media programming, NPN, 


and inclusion of the new tagline “Stronger by Association.” 


Dr. Dennis Killian, PharmD, PhD, 
pharmacy director at Salisbury’s 
Peninsula Regional Medical 
Center, has accepted an offer 
from the University of Maryland 
Eastern Shore School of 
Pharmacy to be the Interim Dean. 
Dr. Killian received his PharmD 
and PhD in pharmaceutical 
Science from the University of 
Maryland School of Pharmacy. 

He also teaches at UMES in 

the areas of pharmacokinetics, 
pharmaceutical calculations and 
pharmacy automation. 


Apple Discount Drugs, owner 

and president Jeff Sherr, was 
recognized by OutcomesMTM 

as a top pharmacy that has 
demonstrated a dedication to 
Medication Therapy Management 
and a commitment to improving 
the health of their patients. Apple 
Discount Drugs performed over 
250 Comprehensive Medication 
Reviews in 2013. OutcomesMTM 
provides monthly updates in their 
national newsletter on Medication 
Therapy Management activities targeted toward pharmacy 
providers across the country. 


The Maryland Chamber of 
Commerce announced Ellen 
Yankellow, president and CEO 

of Linthicum Heights-based 
CorrectRx Pharmacy Services, 

as an inductee into the 2014 
Maryland Business Hall of Fame. 
She will be honored on May 6 
during the Maryland Chamber's 
Annual Meeting & Business Hall 
of Fame Awards Dinner. Yankellow 
Currently is Chair of the University 
of Maryland-School of Pharmacy Board of Visitors and 
serves on numerous other boards. 


Bruce Anderson, PharmD, 
DABAT, was honored by University 
System of Maryland Board of 
Regents with a 2014 Faculty Award 
from the University of Maryland, 
Baltimore. Anderson was the 
regents’ public service winner for 
his work as director of operations 
at the School of Pharmacy’s 
Maryland Poison Center. 
Anderson is also an associate 
professor in the Department of 
Pharmacy Practice and Science 

at the School of Pharmacy. 


Jill Morgan, PharmD, BCPS, 

was also honored by University 
System of Maryland Board of 
Regents with a 2014 Faculty 
Award from the University of 
Maryland, Baltimore. Morgan 

was recognized with the regent’s 
award in mentoring. She is 

an associate professor in the 
Department of Pharmacy Practice 
and Science at the School 

of Pharmacy and its former 
associate dean for student affairs. 


MARYLANDPHARMACIST.ORG 27 


UNIVERSITY of MARYLAND 


EASTERN SHORE 
School of Pharmacy 


October 
is 


LODO 


Tees 
HTH " a] cae ol 
4 ' mei 
a> 
0 bd 


Whether it is in a hospital or a school, at an eldercare UMES Has THE onty 3-YEAR 


CONCENTRATED DOCTOR OF 
PHARMACY PROGRAM IN MARYLAND. 


facility or a pharmacy, in the military, near or far, 
UMES pharmacy graduates are integral to our Nation’s 
commitment to provide every American with quality We are proud to support 


health care. Maryland Pharmacy! 


Visit us at: www.umes.edu/pharmacy 


) i VACCINATIONS 


APP 


A 
| 


closer look into the new 


ROVED 


influenza vaccinations 


PRSRT STD 
U.S. POSTAGE 


PAID 


HARRISBURG PA 
PERMIT NO. 533 


COVER PHOTO ECOGNIZING Sinha aktpegh ha 
NEW PRACTITIONER : Fin NEUROPATHY > 
NETWORK CELEBRATES 
THEIR FIRST ANNIVERSARY 


ie BO ipa °Sa aaa it We 


MARYLAND PHARMACISTS ASSOCIATION JOURNAL | WINTER 2014 


77 | PRESIDENT’S PAD 


LGN" 2 
PEN ; 
x 


UJ 


Collaborative 
Practice may 
sound intimidating, 
but you can do 

it! The Maryland 
Pharmacists 
Association and 
the Professional 
Development 
Committee are 
committed to 
assisting you with 
each and every step 
of the way. 


memes f Ale 


Dear MPhA members, 


Recently | was interviewed by three 
Student pharmacists. One of the students 
asked me the following question, 

“What is unique about your position 

that would make a student want to 

have a similar career?” My answer was 
simple; | have two collaborative practice 
agreements with a physician's group; 
metabolic syndrome and anticoagulation. 
Physicians refer patients to me and 

| schedule visits with them either at 

the pharmacy or in the physicians’ 
offices. | have the ability to adjust 

doses and make recommendations to 
therapy. The physicians are beginning 

to refer patients for Comprehensive 
Medication Reviews. The partnership 
that Fink’s Pharmacy has developed and 
continues to grow has allowed me the 
opportunity to practice pharmacy in very 
innovative ways. Students ask me all the 
time how did Fink’s Pharmacy start a 
collaborative practice with a physician. 
The answer is simple, we asked. The 
Finks identified physicians that they had 
developed strong relationships with and 
asked. Fink’s Pharmacy is still the only 
community pharmacy in the state of 
Maryland with a Collaborative Practice 
Protocol in place. This year we want to 
change that. The MPhA Professional 
Development Committee, co-chaired 

by Kristen Fink and Hoai-An Truong, 

will be hosting a Collaborative Practice 
Webinar series beginning this year. 
Additionally, an article is scheduled to 
be published in the upcoming journal 
regarding compensation opportunities. 
Collaborative Practice may sound 
intimidating, but you can do it! The 
Maryland Pharmacists Association 

and the Professional Development 
Committee is committed to assisting 
you with each and every step of the way. 
Add Collaborative Practice to the top of 
your New Year's to-do list. If you have 
any questions about Fink’s Pharmacy 


2 BB MARYLAND PHARMACIST | WINTER 2014 


Collaborative Practice please feel free to 
contact me at cleerx@hotmail.com 


Finally, following the weekend of the first 
Board of Trustees Meeting we kicked 

off Pharmacy Month with the Third 
Annual Medication Therapy Management 
Summit and what a tremendous success 
it was! Thank you to the Professional 
Development Committee for recruiting a 
program full of dynamic nationally known 
speakers. Many of which are members 
of MPhA including Nicki Brandt, Arnie 
Clayman, Ashley Moody, and Emily 
Pherson. Thank you to the staff and 
students who volunteered at the event 
making sure everything from start to 
finish ran smoothly. A special thank you 
goes to all the committees who donated 
a basket for the Foundation Raffle. The 
fundraiser was so much fun and we will 
be sure to do it again. 


Warm regards, 


O busbinnkn- (.Joor9 


Christine Lee-Wilson, PharmD 
President 


ar Za 


WINTER 2014 


MARYLAND PHARMACIST 


FEATURES | 


At A Glimpse into MPhA‘s New Practitioner Network 


1 A New Vaccinations Approved for the 2013-2014 Season 


1 / Recognizing Excellence — Kristen FINk 


20 Management of Painful Diabetic Neuropathy 


DEPARTMENTS ADVERTISERS INDEX 
2 c 7 MPhA’s Career Center 
President's Pad RO casecr 
8 Corporate Sponsors 13 Bowl of Hygeia Award 
8 welcome New Members 25. puy-sell-A-Pharmacy 
9 Member Mentions 26 Pharmacists Mutual 
10 2014 MPhA Awards 28 University of Maryland 


20 continuing Education 
24 cE Quiz 


Eastern Shore 


MPhA 


EST, 188? MARYLAND PHARMACISTS ASSOCIATION 


MPhA OFFICERS 2013-2014 

Brian Hose, PharmD, Chairman of the Board 

Christine Lee-Wilson, PharmD, President 

Dixie Leikach, RPh, Vice President 

Matthew Shimoda, PharmD, Treasurer 

Frank Palumbo, BSPharm, MS, PhD, JD, Honorary President 


HOUSE OFFICERS 
Chai Wang, PharmD, Speaker 
G. Lawrence Hogue, BSPharm, PD, Vice Speaker 


MPhA TRUSTEES 

Doug Campbell, RPh, 2014 

Nicole Culhane, PharmD, 2016 

Kristen Fink, PharmD, BCPS, CDE, 2015 

Mark Lapouraille, RPh, 2016 

Hoai-An Truong, PharmD, MPH, 2014 

Wayne VanWie, RPh, 2015 

Jane Kim, ASP Student President, University of Maryland 


EX-OFFICIO MEMBERS 
Dennis M. Killian, PharmD, PhD, Interim Dean 

University of Maryland Eastern Shore School of Pharmacy 
Natalie Eddington, PhD, Dean 

University of Maryland School of Pharmacy 
Anne Lin, PharmD, Dean 

Notre Dame of Maryland University School of Pharmacy 
David Jones, RPh, FASCP, MD-ASCP Representative 
Brian Grover, PharmD, MSHP Representative 


CONTRIBUTORS 
Peggy Funk, Maryland Pharmacist Editor 
Interim Executive Director 


PEER REVIEWERS 

Chris Charles, PharmD 

G. Lawrence Hogue, BSPharm, PD 

Hana Kim, PharmD 

Edward Knapp, PharmD Candidate, 2014 
Jamie Nguyen, PharmD Candidate, 2016 
Frank Nice, RPh, DPA, CPhP 

Cynthia Thompson, PharmD 


Special thanks to the following contributors: 
Elsie Prince, Office Manager 

MPhA Communications Committee, chaired by Chai Wang 
Kelly Fisher, Marketing Coordinator 

Graphtech, Advertising Sales and Design 


We welcome your feedback and ideas for future articles 

for Maryland Pharmacist. Send your suggestions to Peggy 
Funk, Maryland Pharmacists Association, 1800 Washington 
Blvd., Ste. 333, Baltimore, MD 21230, or email peggy.funk@ 
mdpha.com, or call 410.727.0746 


A Glimpse into MPhA’s New 


Practitioner Network (NPN) 


Sara Ly, PharmD Candidate 2015, University of Maryland School of Pharmacy 


The mission of the New Practitioner 
Network (NPN) is to provide a venue for 
new practitioners to network as well 
as exchange ideas and information to 
further professional development. By 
Supporting the transition from student 
to pharmacist, the New Practitioner 
Network helps new graduates in 
Maryland by empowering them to 
become advocates for the future of 
their profession. 


The New Practitioner Network 
provides activities and events targeting 
the needs and interests of new 
practitioners. The network is a great 
resource to gain support through 

a close-knit group of mentors and 
peers advocating for the profession 

of pharmacy. As described by P 

Tim Rocafort, co-chair of the events 
Sub-committee, “NPN has helped me 
connect with other practitioners in 
Maryland, share innovative patient care 
ideas, and also just kick back and relax 
after a long day at work.” Furthermore, 
NPN can help ease new practitioners 
into professional life and serve as an 
outlet to Maryland pharmacy outreach. 


Currently, the NPN serves over 200 new 
practitioners in the state of Maryland 
with over 75 of them working in the 
NPN committee! New practitioners 

are defined as any pharmacist who 

has graduated within the past five 
years and currently includes graduates 
from the classes of 2009-2013. The 
NPN is an added benefit of Maryland 
Pharmacists Association’s membership 
and is provided at no additional cost. 


Having recently celebrated the 

first year anniversary of the New 
Practitioner Network in December 
2013, NPN members are fired up about 
the future growth of the committee. 


Deanna Tran, co-chair of NPN states, 
“We are so excited that NPN has taken 
off in its first year. We hope future 
networking, social, and professional 
development events targeted 
specifically for new practitioners brings 
increased involvement and fun times 
for everyone!” 


(4 (4 | believe the 
future of NPN Is In 
bridging the divide 
among pharmacy 
professionals, 
especially as the 

role of pharmacists 
continue to evolve at 
a rate greater then 


ever seen before.” 
— Scott Morrissey 


With the New Year coming into full 
swing, NPN members have been 
working hard to be able to offer an 
exciting array of upcoming events 

for new practitioners across different 
career paths in pharmacy. This includes 
unique opportunities at MPhA’s Annual 
Convention, Mid-Year Meeting, and 
Medication Therapy Management 


Continued on page 6 


4 MB MARYLAND PHARMACIST | WINTER 2014 


by the NPN’ 


“Keep nen : 
Network On" — 


~ Networking event for stude 
“Step Out: Walk to 


_ Stop Diabetes” 


| to help fight to find a cure f yr 


MPhA/MD-ASCP Mid-Year 


Recent events th 
have been hoste 


and new practitioners at M 
Annual Convention 2013 — 


MPhA sponsored a team of — 
pharmacists and student 
pharmacists, raising ove 


diabetes — 


Continuing Education = 
Presentations aes 


Presented at the MPhA # 
Annual Conventionand = 


Meeting 2013 given by and > iene 
targeting new practitioners ae 


G 
ae 
E 


Monthly NPN Happy Hour 


First Happy Hour event. 
at Nick’s Fish House and | 
Grill attended by 17 new 
practitioners and students for 
a relaxing evening of ming 
and networking \ 


New Practitioner Emily 
Pherson presents MTM Pearl: 
“Post-Discharge Pharmacist- 
Provided Home-Based 
Medication Management Pilot” 
at MPhA‘s Third Annual 

MTM Summit 


," ret Gere a 
SS tea 


Sem 


ie 


New Practitioner Ashley Moody 
presents MTM Pearl: “View Through 
the Magnifying Glass of Establishing 
Community Pharmacy Based MTM 
Services” at MPhA’s Third Annual 
MTM Summit 


NPN members 
enjoying “Strike 
Out with NPN” 
bowling social 


MARYLANDPHARMACIST.ORG ff 5 


A Glimpse into MPhA’s New Practitioner Network 
continued 


Summit hosted by MPhA. In addition, NPN is planning 
various personal and professional development activities 
for new practitioners and students such as a Financial 
Planning Crash Course. When asked about the future of 
NPN, member Scott Morrissey expressed, “I believe the 
future of NPN is in bridging the divide among pharmacy 


professionals, especially as the role of pharmacists continue 


to evolve at a rate greater then ever seen before.” Another 
goal for 2014 is to optimize the usage of interactive social 
media and use it as an adjunct to help build stronger 
connections within our network of Maryland new 
practitioners. 


While any practitioner that has been in practice for five 


years or less and student pharmacists in their third or fourth 
year are eligible to attend NPN events, the committee is also 


seeking enthusiastic individuals looking for opportunities 

to get involved professionally early-on and shape their 
burgeoning career. The New Practitioner Network holds 
monthly committee meetings open to all members to 
discuss and devise action plans for upcoming events. “We 
are always brainstorming and thinking of new ways to have 
our ideas heard,” states Kristen Dominik, co-chair of the 
events sub-committee. Since its recent launch the NPN 
committee has made significant strides in developing a 
Solid infrastructure to support the growth and development 
of NPN. The operational efforts of NPN are split into the 
following three sub-committees: 


New Practitioners and 
Students at Nick’s 

Fish House and Grill 
enjoying the first monthly 
NPN Happy Hour 


Top row (left to right): 

Lauren Lakdawala, Tim Rocafort, 
Chris Charles, Kristen Dominik, 
Jamie Elsner, Dave Goffman 


Middle row (left to right): 
Lubna Kousa, Linda Quach, 
Ashley Moody, Susan Pajak 


Bottom row (left to right): 
Ashley Pham, Deanna Tran 


6 MM MARYLAND PHARMACIST | 


e Public Relations: The Public Relations sub-committee’s 


mission is to expand the professional scope of NPN by 
strategically relaying information to target the audience of 
pharmacists and student pharmacists. The sub-committee 
strives to build invaluable relationships by increasing 
participation in NPN hosted events that will further the 
growth of its membership. 


Events: The Events sub-committee aids the transition of 
student pharmacists into new practitioners in Maryland. 
This is accomplished by providing an avenue for new 
practitioners and seasoned pharmacists to network and 
exchange ideas while engaging in community service 
activities and social excursions. 


Programming: The Programming sub-committee 
coordinates and plans professional development 

events, such as CE presentations and student-specific 
programming that help new practitioners grow both 
personally and professionally, as well as keep an edge on 
their practice. 


Involvement with any one of the NPN sub-committees 
offers many leadership opportunities and the chance 
to implement innovative ideas, and access to a 
Support network. More information on NPN and how to 
become involved can be found on the MPhA website 
(marylandpharmacist.org), or by contacting either of 
NPN’s committee co-chairs: 


e Deanna Tran — tran.deanna@gmail.com 
e Ashley Moody — mccabe.ashley@gmail.com 


NOlsyi> 


€$7, 982 


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Benefit from Using the Career Center? 


Search Through Today’s Most Relevant 


Opportunities 

Nothing is more frustrating than sifting 
through job after job that just do not fit your 
needs. We post only the most relevant jobs 
from the leading employers in our industry. 
Employers come to MPhA’s Career Center 
looking for the best and the brightest. 
They’re looking for you! 


Customized Job Alerts 

Create a Job Seeker Profile and receive Job 
Alert Notifications when an opportunity 
matching your criteria is posted. 


Apply for Jobs 

Quickly apply for jobs and share your 
resume with employers either directly or 
anonymously. 


MPh 


MARYLAND PHARMACISTS ASSOCIATION 


CAREER 
CENTER 


Can You Afford Not to Be Recruiting the Best? 


How As An Employer Can You Benefit 
from Using the MPhA Career Center? 


Save Time and Resources 

Hiring the wrong person costs not only 
time and money but can hurt company 
morale and productivity. Our Trusted 
Talent Advisors can share Best Practices, 
as well as other resources to assist you in 
writing an aligned job description focusing 
on Scope, Scale, Sophistication and Staff. 


Recruit Top Talent 

Target highly engaged MPhA members and 
experienced professionals committed to 
the advancement of our industry. 


Direct Recruitment Opportunities 

Take advantage of search, email and online 
advertising options to directly recruit top 
candidates. 


Visit the MPhA’s Career Center today! 
http://www.marylandpharmacist.org/ 


pARAACis re 
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ry ‘a 

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2 = 


S57, 198? MARYLAND PHARMACISTS ASSOCIATION 


—_—_ 
ey, Ae) 


Thank you to our 
Corporate Sponsors 


Boehringer Ingelheim ‘McKesson 

CARE Pharmacies, Inc. Nutramax Labs 

CVS Caremark Pharmacists Mutual Companies 
EPIC Pharmacies, Inc. Value Drug 

FreeCE.com Walgreens Co. 


Kaiser Permanente 


Came to our newest members! 


Ganiyat Awokoya Lauretta Kerr Elizabeth Oladele 

Emily Dvorsky Nicholas Ladikos Venkateswara Pavuluri 
Joseph Fine Ann Lang Megan Resch 

Muted Fofung Michele Leonardi Chaltu Wakijra 

Beth Fritsch Marybeth Missenda James Santford Williams 
D. Christopher Green Mary-Pat Morris Jovonne Williams 

Isiah M Harper Chukwuma Obi Stephen Zelinsky 
Cassandra Jakubowski 


Ay Stay Connected! 
IMPhA MarylandPharmacist.org in wy 


77> | MEMBER MENTIONS 


American Association of Colleges of 
Pharmacy Selects President-Elect 


Entrepreneur of the 


Cynthia J. Boyle, MPhA past President and 
Year Named 


former Foundation President, has been selected 
to be the new president-elect of the American 
Association of Colleges of Pharmacy. She finished 
her term as Speaker of the House for AACP this 
past July and will assume its top office in mid- 
2015 after serving the next academic year as 
president-elect. 


Magaly 
Rodriguez 
de Bittner, 
professor and 
chair of the 
Department 
of Pharmacy 
Practice 

and Science 
at the 
University Magaly Rodriguez 
of Maryland de Bittner 

School of Pharmacy, has been 


Cynthia Boyle 


Patient Safety Pharmacy Collaborative 
Award Recipient 


Selected as the University of 
Maryland, Baltimore's Entrepreneur 
of the Year. Dr. Bittner has lead 

the implementation of nationally- 
recognized programs, such as 

the Maryland P3 Program and 
consistently demonstrates the role 
of a professional in her field. She is 
the first women ever to receive 
this award. 


For the second year in a row, Jennifer Thomas has 
been selected as the Patient Safety Pharmacy Collabora- 
tive (PSPC) Award recipient for the Quality Improvement 
Organization Partner Award. This award recognizes an 
individual/organization within the QlIO community that 
has adopted the PSPC culture and works tirelessly to 
Support all teams within and/or outside their region. 

Due to Jennifer's vigorous efforts, she has increased . 
the number of active PSPC teams from one to seven in = Jennifer Thomas 
Maryland and the District of Columbia. 


2014 Community Pharmacy 
Residency Excellence in 
Precepting Award Recipient 


The College of Psychiatric and 
Neurologic Pharmacists Elects 
President-Elect 

Cherokee Layson- 
Wolf, PharmD, 
associate dean for 
Student affairs and 
associate professor 
of pharmacy practice 
and science, has 
been selected to 
receive the American 
Pharmacists 
Association’s 2014 Cherokee 
Community Pharmacy /ayson-Wolt 
Residency Excellence 

in Precepting Award. 


The College of Psychiatric and Neurologic 
Pharmacists (CPNP) membership has 
elected Dr. Raymond Love to serve as 
President-Elect on the 2014-2016 Board 
of Directors. Dr. Love is also currently 
serving as Member at Large to the Board. 
CPNP is a professional association of over 
1,100 members dedicated to promoting 
excellence in pharmacy practice, education 
and research to optimize treatment 
outcomes of individuals affected by 
psychiatric and neurologic disorders. 


Raymond Love 


In the Fall 2013 issue of Maryland Pharmacist, Sajal Roy’s name was misspelled. Dr. Roy is the 
newest appointee to the Board of Pharmacy appointed by Governor Martin O'Malley. 


CORRECTION 


MARYLANDPHARMACIST.ORG 


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2014 Ma ad 
Pharmacists Association Awa rds | 


ryland 


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Each year, MPhA recognizes individual professional excellence during the Annual MPhA Convention held in Ocean City, MD. 
To nominate a deserving pharmacist for one of the awards described below, complete and submit the nomination form 
below to: Award Nominations, c/o Maryland Pharmacists Association, 1800 Washington Blvd., Suite 333, Baltimore, Maryland 
21230-1701. Nominations can also be submitted online at marylandpharmacist.org. For consideration, nomination 
forms must be received no later than Friday, March 28, 2014. 


Nominations are reviewed and selections made by the Past Presidents Council. Upon selection, individuals will be notified in 


advance of the Annual Convention. 


Bowl of Hygeia Award sponsored by the 

American Pharmacists Association Foundation and 
National Alliance of State Pharmacy Associations 
Boehringer Ingelheim — Premier Supporter 


Established in 1958, the Bowl of Hygeia Award recognizes 
pharmacists who possess outstanding records of civic leadership 
in their communities and encourages pharmacists to take active 
roles in their communities. In addition to service through their 
local, state, and national pharmacy associations, award recipients 
devote their time, talent, and resources to a wide variety of causes 
and community service. Any MPhA member pharmacist who 

has not already received the Bowl of Hygeia Award is eligible for 
nomination. 


The Bowl of Hygeia is the most widely recognized international 
symbol for the pharmacy profession and is considered one of 

the professions most prestigious awards. The Bowl of Hygeia has 
been associated with the pharmacy profession since as early as 
1796, when the symbol was used on a coin minted for the Parisian 
Society of Pharmacy. The bowl represents a medicinal potion and 
the snake represents healing. 


Understanding the value of the Bowl of Hygeia to the profession of 
pharmacy, and the need for the managing organizations to focus 
on fundraising for an endowment, Boehringer Ingelheim stepped 
in to become the Premier Supporter of the Bowl of Hygeia program 
in 2012. This allows the base funds that have been previously 
donated to stay intact while an endowment fundraising program 
continues. 


Maryland Pharmacists Association Seidman 
Distinguished Achievement Award 


Created by Henry Seidman, this award honors a Maryland 
pharmacist who has performed outstanding service over a number 
of years, and whose service has resulted in a major impact on the 
pharmacy profession. MPhA pharmacist member who meet the 
criteria for this award are eligible for nomination. 


10 §§ MARYLAND PHARMACIST | 


Excellence in Innovation Award 
sponsored by Upshire-Smith Laboratories, Inc. 


Established in 1993, this award aims to recognize forward-thinking 
pharmacists who have expanded their practices into new areas. 
Any practicing MPhA pharmacist member within the geographic 
area who has demonstrated innovative pharmacy practice 
resulting in improved patient care is eligible for nomination. 


Distinguished Young Pharmacist Award 
sponsored by Pharmacists Mutual Companies 


This award is presented each year to a pharmacist who has 
graduated within the past ten years and has made a significant 
contribution to the profession through service to a local, state, or 
national pharmacy organization. Any MPhA pharmacist member 
who has graduated from a school of pharmacy within the last ten 
years is eligible for nomination. 


Maryland Pharmacists Association Mentor Award 


This award recognizes individuals who encourage pharmacists, 
technicians, and/or student pharmacists in the pursuit of 
excellence in education, pharmacy practice, service, and/or 
advocacy. Any MPhA pharmacist member who meets the criteria 
for the award is eligible for nomination. 


Cardinal Health Generation Rx Champions Award 
sponsored by Cardinal Health Foundation 


This award honors a pharmacist who has demonstrated 
outstanding commitment to raising awareness of the dangers of 
prescription drug abuse among the general public and among the 
pharmacy community. Any MPhA pharmacist member who meets 
the criteria for the award is eligible for nomination. 


Maryland Pharmacists Association Honorary President 


An honorary position on the Board of Trustees is given to a person, 
not necessarily a pharmacist, who has worked for MPhA or 
Maryland Pharmacy over a long period of time. Any long standing 
contributor to the profession or the Association is eligible for 
nomination. 


Award Nomination Form 


To nominate an individual for one of MPhA‘s annual Recognizing Pharmacy Excellence awards, complete and return this form to 
Award Nominations, C/O Maryland Pharmacists Association, 1800 Washington Blvd., Suite 333, Baltimore, MD 21230, no later than 
Friday, March 28, 2014. All nominations will be held in strictest confidence by the MPhA Past Presidents Council, which is responsible 
for selecting the award recipients. The decision of the Council is final. Award recipients will be notified in advance of the presentation 
of the award. 


Please provide the information as requested for each nominee and attach a current resume or a curriculum vita that demonstrates 
their professional and personal achievements. This information is essential for the Past Presidents Council to make well-informed 
decision as to which candidates will be selected. Also please include a brief statement explaining why the nominee is deserving of the 
award. If you would prefer to make your nomination online, visit marylandpharmacist.org. 


Bowl of Hygeia Award sponsored by the 
American Pharmacists Association Foundation and 
National Alliance of State Pharmacy Associations 


City/State/Zip 


Daytime Phone 


Nominee Employment/Practice 


Address Nominated by 


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Employment/Practice 


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sponsored by Upshire-Smith Laboratories, Inc. Maat 


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MCKESSON 


with 
NMicKesson 


TPO OHHH O HEHEHE HHH EHH THEE EH EH EEEHESHH ESE HESS HEHE EEEED 
. 


Growth Starts with a Strong Foundation 


For 178 years, McKesson has been delivering to independent 
pharmacies — making sure you have the right product, at the 


| 3 } ; McKesson Is proud 
right time, at the right price. : 


: to support the Maryland 
Today, we are partnering with pharmacy owners, like you, Pharmacists Association. 
to help you grow revenues, maximize reimbursements and 

strengthen patient relationships. 


. 
eee eee eee eee eee eee ee eee eee eee eee eee eee ee eee eek 


Call 866.329.0113 or visit 
www.growwithmckesson.com 
to learn how we can help you flourish. 


2013 Recipients of the “Bowl of Hygeia” Award 


Charles D. Sands Ill Martie Lamont Kathryn Labbe Karrol Fowlkes Vicki Fowlkes Helen K Park Ronald Kennedy Gregory L Hancock 


Alabama Alaska Arizona Arkansas* Arkansas* California Colorado Connecticut 


ie 


David W. Dryden Judith Martin Riffee William Lee Prather Selma Yamamoto Mark Johnston Garry Moreland Patrick Cashen Bernard Cremers 
Delaware Florida Georgia Hawaii \daho Illinois Indiana lowa 


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Paul Chace Angelo C. Voxakis John R Reynolds 


Leland Hanson J Leon Claywell Douglas Boudreaux 
Kansas Kentucky Louisiana Maine Maryland Massachusetts 


= ema 
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Sa. 


Nancy J W Lewis Harvey Buchholz Clarence DuBose 
Michigan Minnesota Mississippi 


Kenneth W. Schafermeyer Carla Cobb Scott E Mambourg 
Missouri Montana Nevada 


- 


Cheryl A Abel Eileen Fishman Phil Griego James R. Schiffer Jean Douglas Laurel Haroldson Kenneth S. Alexander Eric Winegardner 
New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma 


ee 


Wayne Kradjan Edward Bechtel Daniel Mahiques-Nieves Linda A Carver Linda Reid Ann M Cruse Kenneth Smith Leticia Van de Putte 
Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas 


Dominic DeRose Leo H Ross Janet Kusler Russell Jensen Timothy Seeley 
Utah Virginia Washington Wisconsin Wyoming 


The Bow! of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation 
for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these 
dedicated individuals has made uniquely personal contributions to a strong, healthy community. We offer our congratulations and thanks 
for their high example. The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the 
state pharmacy associations have assumed responsibility for continuing this prestigious recognition program. All former recipients are 
encouraged to maintain their linkage to the Bowl of Hygeia by emailing current contact information to awards@naspa.us. The Bowl of 
Hygeia is on display in the APhA Awards Gallery located in Washington, DC. 


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Boehringer Ingelheim is proud to be the Premier Supporter of the Bowl of Hygeia program. 


*husband and wife co-recipients 


aay: Approved 
for the 
013-2014 
season 


Bee 


A ie ace into the 
S\¥4 new influenza vaccinations 
and the expanded 
recommendation for the 
pneumococcal vaccination, 
PCV13 (Prevnar 13). 


7 : Hana Kim, PharmD, PGY- 1 masident, 
anente of the Mid-Atle an 


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14 §) MARYLAND PHARMACIST | \\V\! 


With the flu season approaching, 
pharmacists can anticipate an influx 
of influenza vaccinations, as well 

as pneumococcal vaccinations. It is 
important to always stay up to date 
with any new vaccines or updated 
recommendations. For the 2013-2014 
season, five new influenza vaccines 
were introduced, in addition to an 
expansion of recommendations 

of the pneumococcal vaccination 
(Prevnar13). 


Flu seasons can be unpredictable 

in terms of the influenza strain and 
severity. The Centers for Disease 
Control anticipates possible strains 
yearly in order to develop the season's 
influenza vaccinations. Previously, 
trivalent vaccinations have been 
available on the market. Trivalent 
influenza vaccines contain three 
different strains of the influenza virus, 
protecting against two influenza A 
viruses and one influenza B virus. 
This year, a quadrivalent vaccination 


Table 1 ¢ New Influenza Vaccinations Available for the 2013-2014 Season 


VACCINATION | FORMULATION | APPROVED FOR 


2-49 years of age 


FluMist 
Quadrivalent' 


Nasal spray 


Live attenuated, 
quadrivalent 


Intramuscular 
(IM) injection 


Fluarix 
Quadrivalent? 


Inactivated, 
quadrivalent 


Fluzone 
Quadrivalent? 


IM injection 


Inactivated, 
quadrivalent 


Flucelvax* - IM injection 


Recombinant 
hemagglutinin 


*If 2 doses, administer 1 month apart 


3 years of age 
and older 


6 months of age 
and older 


18 years of age 
and older 


With the flu season 
aproaching, pharmacists 
can anticipate an intlux 


of influenza vaccinations. 


was formulated to protect against 
four strains, two influenza A and two 
influenza B viruses. 


Five new vaccines have been 
approved and are marketed for this 
season: FluMist Quadrivalent, Fluarix 
Quadrivalent, Fluzone Quadrivalent, 
Flucelvax, and Flublok. Table 1 
describes the new vaccinations 
available. Flucelvax and Flublok 

are manufactured in a manner that 
does not rely on using egg proteins, 
which may offer an option to patients 
with an anaphylactic egg allergy. 
Flucelvax may still contain very 
small, immeasurable amounts of 


e 2-8 years of age: 
one or two doses, * 
0.2 mL each 


e 9-49 years of age: 
1 dose, 0.2 ML 


egg protein. Flucelvax has not been 
directly studied in patients with egg 
allergies.’ Flublok is the only vaccine 
available that does not contain any 
egg protein. It is also still important 
to consider the risk of using a live 
vaccine in patients who are pregnant 
or immunocompromised. 


In addition to the new influenza 
vaccines, a new pneumococcal 
vaccine has been introduced this 
year. Current guidelines recommend 
the 23-valent polysaccharide vaccine 
(PPVSV23), Pheumovax, for adults 
older than 65 years of age and for 
those who are 2 years of age and 
older at high risk for disease. It is also 
recommended for adults 19-64 years 
of age who smoke or have asthma. 
The newer agent, pneumococcal 
conjugate vaccine 13, PCV 13 (Prevnar 
13), was approved in 2010 only for 
use in children. In 2011, the vaccine 
was approved for those older than 50 
years of age. In June 2013, the CDC’s 


bposes a CONTRAINDICATIONS PREGNANCY 


e History of severe allergic reaction | Pregnancy Category: B 
to any component of the vaccine | Safety and efficacy not 
(including egg product), or 
following a previous dose of any 
influenza vaccine 


established in pregnant or 
nursing women 


e Concomitant aspirin therapy in 
children and adolescents 


¢ 3-8 years of age: 
one or two doses* 
(0.5 mL, each) 


e History of severe allergic reaction | Pregnancy Category: B 
to any component of the vaccine | Safety and efficacy not 
(including egg product), or 
following a previous dose of any 


established in pregnant or 
nursing women 


influenza vaccine 


e 6-35 months of 
age: one or two 
doses* (0.25 mL, 


e 36 months to 8 
years of age: one or 
two doses* (0.5 mL, 
each) 


e 9 years of age and 
older. one dose 
(0.5 mL) 


Single 0.5 ML 
injection 


e History of severe allergic reaction | Pregnancy Category: C 
to any component of the vaccine | Safety and efficacy not 
(including egg product), or 

each) following a previous dose of any 

influenza vaccine 


established in pregnant or 
nursing women 


e History of severe allergic reaction | Pregnancy Category: B 
to any component of the vaccine | Safety and efficacy not 
(including egg product), or 
following a previous dose of any 


established in nursing 
women 


influenza vaccine 


MARYLANDPHARMACIST.ORG {i 15 


Advisory Committee on Immunization 
Practices (ACIP) expanded the 
recommendation of PCV13 to adults 
equal to or older than 19 years of 

age who have immunocompromising 
conditions, functional or anatomic 
asplenia, CSF leaks, or cochlear 
implants. In addition, those who are 
naive to pneumococcal vaccine within 
the previously mentioned patient 
population should receive a dose of 
PCV13 first, then a dose of PPSV23 at 
east 8 weeks later.® 


When considering coadministering 
the pneumococcal and influenza 
vaccination, keep in mind the timing 
of administration of both vaccines. It 
has been reported that the inactivated 
influenza and PCV13 may cause 

a diminished antibody response 

to PCV13.’ It is recommended to 
Separate doses by approximately 

one month. 


16 MB MARYLAND PHARMACIST | 


Pharmacist-administered 
vaccinations is one way 
we can offer quality 
patient care. 


With the new influenza vaccinations 
and updated recommendations for 
the PCV13 vaccination, it is important 
to consider patient characteristics. 
For example, always keep in mind 
pregnant or nursing patients and 

the patient’s age. Specifically, 

these two factors can change the 
recommendation for the type and 
timing of vaccinations. As pharmacists, 
we play an integral role in patient 
care, and pharmacist-administered 
vaccinations is one way we can offer 
quality patient care. 


REFERENCES 


mn 


uMist Quadrivalent [package insert] Gaithersburg, MD: 


" Medimmune, LLC; 2013 


uarix Quadrivalent [package insert] Research Triangle Park, 


PM 
NC: GlaxoSmithKline; 2012. 


mn 


uzone Quadrivalent [package insert] Swiftwater, PA: Sanofi 


balm, 
Pasteur Inc.; 2013. 


ucelvax [package insert] Cambridge, MA: Novartis Vaccines 
and Diagnostics Inc.; 2012. 


Flublok [package insert] Meriden, CT: Protein Sciences Corp.; 
2013. 


U.S. Food and Drug Administration. Vaccines Licensed for 
Immunization and Distribution in the US with Supporting 
Documents. http://www.fda.gov/BiologicsBloodVaccines/ 
Vaccines/ApprovedProducts/ucm093830.htm Updated 
February 19, 2013. Accessed June 10, 2013. 


U.S. Food and Drug Administration. Flucelvax clinical review. 
http://www. fda.gov/downloads/BiologicsBloodVaccines/ 
vaccines/ApprovedProducts/UCM332069.pdf November 20, 
2011. Accessed July 3, 2013. 


CDC. Licensure of a 13-valent pneumococcal conjugate 
vaccine (PCV13) and recommendations for use among 
children—Advisory Committee on Immunization Practices 
(ACIP), 2010. MMWR 2010;59:258-61 


Prevar 13 [package insert] Philadelphia, PA: Pfizer; 2013. 


. Pneumovax 23 [package insert] Whitehouse Station, NJ; 


2013. 


MPhA 
132nd Annual 
Convention 


Clarion Fontainebleau Hotel 
Ocean City, MD 
June 13-16 


4 
6 
NOlyId°” 


€sT, 1982 


MARYLAND PHARMACISTS ASSOCIATION 


| 
ea 


MEMBER SPOTLIGHT 


RECOGNIZING 


Kristen Fink 


Cynthia J. Boyle, PharmD, FAPhA, FNAP 
Professor and Chair, Department of Pharmacy Practice and Administration 
School of Pharmacy, University of Maryland Eastern Shore 


The annual Maryland Pharmacists Association awards luncheon is a highlight of the June convention, but 
if you were not able to attend, you may have only read the names of the honorees. This Member Spotlight 
article is one in a series that will feature award winners and distinctive members. The first featured award 
winner is Kristen Fink, recipient of the 2012 MPhA Excellence in Innovation Award. 


AWARD BACKGROUND 


Established in 1993, this award (formerly 
known as the Innovative Pharmacy 
Practice Award) aims to recognize 
forward-thinking pharmacists who 

have expanded their practices into new 
areas. Any practicing MPhA pharmacist 
member within the geographic area 
who has demonstrated innovative 
pharmacy practice resulting in improved 
patient care is eligible for nomination. 
The Excellence in Innovation Award is 
decided by the MPhA Past Presidents’ 
Council and supported with a stipend 
from the MPhA Foundation. 


RECIPIENT BACKGROUND 


Kristen Fink, PharmD, BCPS, CDE, 
graduated from Duquesne University 

in 2004 and completed a Managed 

Care Pharmacy Practice Residency at 
Kaiser Permanente. Dr. Fink is currently 
the Director of the Post Graduate Year 

1 (PGY1) Residency Program at Kaiser 
Permanente, and Clinical Pharmacy 
Specialist specializing in outpatient 
primary care. She also educates, 
monitors, and manages medications 

for diabetic patients at Fink’s Pharmacy, 
her family’s independent pharmacy in 
Essex, Maryland. As the first independent 
pharmacist in the State of Maryland 

to practice drug therapy management 
under an approved Collaborative Practice 
Agreement, Dr. Fink collaborates with her 
physician partners to help care for their 
diabetic patients. 


Kristen Fink serves as a trustee for MPhA 
and as co-chair of the Professional 
Development Committee for the past 
seven years. 


Former Past President Neil Leikach 
with Kristen Fink 


MARYLANDPHARMACIST.ORG (if 17 


(\ with Dr. Fink 


What were your thoughts 

when you heard you would 

be recognized with the MPhA 
Excellence in Innovation Award? 


What an honor to even be nominated 
for such an award. It is exciting to 
embark on a new adventure and 
develop a new practice. | was thrilled 
to be able to do it, hopefully paving 
the way for other pharmacists to begin 
collaborative practices. 


What were the most important 
steps toward your innovative 
practice? 


First | needed to demonstrate 

the value | could add to diabetes 
management of our patients. Since 
this was a new practice model for the 
first physician with whom | partnered, 
| was excited to show him how | could 
educate patients and monitor and 
adjust their medications to achieve 
quality goals. He gave me his most 
difficult and resistant patients at first. 
As they started working with me and 
coming back to their next physician 
visit with significantly improved 
symptoms and lab results, he could 
see the results immediately. 


What was the major barrier for 
your innovative practice? 


Initially it was sunset for the law 
allowing collaborative practice within 
the State of Maryland. The hard-fought 
opportunity for collaborative practice 
was due to expire. Once that was 
resolved through advocacy, it was 
Simply the misunderstanding of our 
practice by the Board of Physicians, 
along with their hesitance to renew 
Our agreement in a timely manner. 
We had a second group of physicians 
who had heard about how we could 
help with diabetes management. 


They were waiting to get involved, 

but without Board approval, we were 
stuck treading water. Luckily, after 
testifying to the Board of Physicians 
along with my physician partners, that 
issue has now been resolved, and 

the regulations have been re-written 
to avoid this barrier for us and other 
Maryland pharmacists in the future. 


What will it to take for your 
innovation to become a standard 
of practice? 


The will of the pharmacists! We 

are fully capable of working within 
collaborative agreements to modify 
and optimize medication therapies. 
Our education and training is 
specifically in the area of medication 
management, so who knows the 

ins and outs of the medication 
management better than we do?!?! 
We also need to figure out the 
reimbursement piece of the equation. 
The tremendous value of pharmacists 
through cognitive services has been 
proven again and again in all different 
practice settings. But insurance is 

Still lagging in that pharmacists’ 
reimbursement Is tied to the product. 
Hopefully this will change as pharma- 
cists obtain provider status. 


How were you able to use the 
award stipend from the MPhA 
Foundation? 


The stipend was a fantastic kick-start 
for new equipment in our everyday 
practice. It was also used for a 
database to help prove our outcomes. 
We spent some for the application 
fee to apply for American Association 
of Diabetic Educators (AADE) 
accreditation for our group education 
series. Hopefully that seed money 
will turn into real reimbursement 
funds for our educational efforts 

with the accreditation. 


18 MB MARYLAND PHARMACIST | WINTER 2014 


It takes knowledge, skills, and 
abilities to innovate. To what do 
you attribute your success? 


| have been fortunate to have had 
training in starting a new clinic. | know 
that building the relationships is the 
most important part. Fortunately 

for me, my father has excellent 
relationships with many physicians 
throughout the Essex area, so it was 
easier for me to build off of those 
relationships to start this practice. 

| have always believed that | can 
accomplish anything that | put my 
mind to, so it never crossed my mind 
that we would not succeed. After 
that it was a matter of adjusting 

to challenges, and persevering to 
accomplish the goal. 


You are a Dusquesne grad. What 
advice do you have for student 
pharmacists at your alma mater 
or in Maryland? 


Believe in yourself and your abilities. 
Know that you have the training to be 
a great pharmacist and master any 
part of the field. Find the part of the 
profession that you have passion for, 
and pursue it with everything that you 
have. With that mindset, each day you 
go to work will not feel merely like a 
job. It will become your career and 
calling. 


How are you able to serve as a 
trustee of MPhA, an innovative 
pharmacist, and a wife and 
mother? What does work-life 
balance look like? 


My first thought was, “What work-life 
balance?” It all blends into one for me! 
In all honesty, | have been “accused” 
of living and breathing pharmacy, 

but it is in my blood and | love it. | 
love seeing our profession change, 
grow, and take on new challenges. 
When | took the BCPS exam, | told my 
husband that | would take a break 
after it was over. He knew | would 
find something new to tackle by the 
next week - and he was right! | am 
extremely fortunate that Andrew is 
SO supportive, and we always put 

a high priority on having fun too — 


taking the time out to travel, trying 
different restaurants, and embarking 
on new adventures. We just had our 
son, Ethan. He is 3.5 months old now, 
and he has definitely changed my 
perspective. | have to say that my 
biggest hobby is just watching him 
laugh and discover new things for the 
first time. Who knows? Maybe he will 
love pharmacy too and continue the 
family tradition! 


How have your leadership skills 
developed as a volunteer leader? 


| enjoy teaching and providing 
opportunities to others. | motivate 
people through role modeling. For 
example for the residency program, 
| like to organize weekly calls and 
give others the chance to volunteer 
for what they want to do. In other 
words, | match their talents with the 


e Crystal Heise 

e Sherifat Fakunle 
e Kristin Fink 

e Jennifer French 
e Ed Galligan 

e Edward Geotz 

e Lillie Golson 

e Felix & Mary Therese Gyi 
e Andrew Haines 

e Stephen Handelman 


Thank YOu to our 


2013 Maryland Pharmacists Association 


e Marcus Lachapelle 
Mark Lapouraille 

e John & Donna Larkin 
e Chung Lee 

e Neil & Dixie Leikach 
e Phillip Marsiglia 

e David McCagh 

e Chukwuma Okeke 

e Jack Peters 


tasks. We create short deadlines 

with regular follow-ups. | give people 
equal preference and don't shoot 
down ideas. The same works for the 
Professional Development Committee 
which continues to grow. 


How do your colleagues 
describe you? 


| am not sure. | would hope they think 
| am positive, up-beat, hard-working 
and dedicated. 


What does MPhA membership 
mean to you? 


MPhA has been wonderful for me. 
When | first moved back to the state, 
MPhA was the place that | went to 
find out what was happening in the 
pharmacy world in Maryland. | was 
welcomed with open arms. | have 


Member Level 


($25-$100) 
e Community Health e Robert Henderson e Beverly Rivenburg 
Sen is National. ~rnie Honkofsky ° Mr. & Mrs. Andy 
rea, INC. 
© Brian Hose Schcroeder 


e Doris Voigt 


e Gary Wirth 


e Jennifer Thomas 


e Wedgwood Club 
e Christine Lee-Wilson 


always found MPhA to be a very 
welcoming and upbeat organization. 
Members like to collaborate and 
support anyone trying to grow the 
profession - and they have fun 

in Ocean City during the annual 
convention! 


What does your pharmacy future 
look like? 


|am not sure. When my term as 
trustee is over, | Know | want to be 
involved. Maybe | will work through 
the MPhA Foundation or the Maryland 
Board of Pharmacy. | am optimistic 
about our profession. If pharmacists 
take that first step, we can go far. 
we can all do collaborative practice 
and patient care. Patients face many 
chronic conditions. We need to step 
up and help them. 


Foundation 
donors! 


MPhA Foundation’s mission is to invest in the future of pharmacy by supporting student pharmacists, recognizing 
practice innovation and advancements, and enhancing philanthropy that supports leadership. 


Our Donors make a difference, thank you. 


B. Olive Cole Level 
($101-$500) 
e Cynthia Boyle 
e Douglas & Jean Campbell 
e Matthew Shimoda 


MARYLANDPHARMACIST.ORG fi 19 


CONTINUING EDUCATION 


Elam Rahgozar, Stud@gmenarmegists 


erson, PharmD, BC 7 ; 
iversity of Maryland School of pharmacy, Beygriore 


PS, CPE, ProfessOPend Vicamaiger 


J 


anagement of 
» Painful 
Diabetic Neuro patny 


Mr. Smith approaches the counter in your community pharmacy 
and asks “My feet are freezing cold at night. | was thinking 

this heating pad might be helpful. What do you think?” You 

pull Mr. Smith’s medication profile and find he is taking the 
following medications: 


e HCTZ 25 mg by mouth daily 

e Simvastatin 40 mg by mouth daily 

e Lisinopril 20 mg by mouth daily 

e Metformin 1000 mg by mouth twice daily 
e Januvia 100 mg by mouth daily 

e Metoprolol XL 50 mg by mouth daily 

e MVI one by mouth daily 


You see that he has a history of hypertension, hypercholesterol- 


emia, and type 2 diabetes mellitus. You ask him if he has mentioned 


the cold feet to his physician and he responds “Oh yes, he said it 


was due to the diabetes. Something about nerve damage. | didn’t 


quite understand what he was getting over." 


20 M§ MARYLAND PHARMACIST | WIN 


Mr. Smith most likely has diabetic 
peripheral neuropathy (DPN), a chronic 
complication often associated with 
diabetes mellitus. Diabetic neuropathy 
is a type of nerve damage resulting 
from chronic hyperglycemia, affecting 
up to 50% of patients with long term 
diabetes, although not all experience 
pain or pain of an intensity that 
requires treatment.' These injured 
nerves will discharge spontaneously 

in response to both painful and non- 
painful stimuli. As a result, the patient 
may be prone to allodynia (pain from 
a non-painful stimulus such as touch) 
and hyperalgesia (increased sensitivity 
to pain). This may manifest as 
numbness, tingling, or pain in the toes, 
feet, legs, hands, arms, and fingers. 
Neurologically, the longest nerve axons 
are affected first, hence, a “stocking- 
glove” distribution is seen with pain 
and abnormal sensations starting in 
the toes and expanding up the legs 
and into the hands. 


Learning objectives 


After reading this article, you will be able to: Key Words pain management 


Describe the pathophysiology and clinical presentation 
of painful diabetic neuropathy. 


List evidence-based treatment options for the 


Painful diabetic neuropathy 
Tricyclic antidepressants (TCA) 


management of painful diabetic neuropathy. Gabapentinoids 


peutic regimen used to treat painful diabetic 
neuropathy, including an initial dose and dose range. 


The assessment of DPN includes neuropathy and should be considered 
a thorough history and peripheral in all diabetic patients for both 
neurologic and vascular examination. the prevention and management 
Comorbid neurologic and vascular of neuropathy. 


abnormalities associated with DPN 
put the patient at risk for poor wound 
healing, infections, and in severe 
cases, amputations of the toes, 

foot or leg. When DPN causes pain, 
patients may describe the sensation 
as burning, stabbing, shooting pain, 
or an electric shock.’ Painful diabetic 
neuropathy specifically refers to 

pain as described in the extremities; 
diabetic neuropathy is a more global 
description that can result in urinary 
tract problems, digestive system 
abnormalities, blood vessel disease 
and heart failure.? 


The management of painful diabetic 
neuropathy is primarily symptomatic. 
Traditional analgesics such as 
acetaminophen or nonsteroidal anti- 
inflammatory drugs are not effective in 
the management of neuropathic pain, 
including painful diabetic neuropathy. 
The Neuropathic Pain Special Interest 
Group of the International Association 
for the Study of Pain recently 
published guidelines for the treatment 
of neuropathic pain of all types.’ They 
acknowledge in these guidelines 

that most randomized clinical trials 
evaluating the management of 


Painful diabetic neuropathy is a neuropathic pain primarily show 
chronic condition with no effective partial relief in no more than half of 
treatment. Research has clearly patients. Additionally, the development 
demonstrated that enhanced glucose of adverse effects is fairly common, 
control significantly reduces the risk and patients frequently are unable 
of developing clinical neuropathy, to tolerate treatment. Despite these 
reducing nerve conduction and limitations, this group developed 
vibration threshold abnormalities.’ recommendations for first-, second-, 
Additionally, the progression of and third-line medications for the 
the disease may be delayed with management of neuropathic pain. 
improved glycemic control and First-line recommendations include 
patient education.*® The Oslo study tricyclic antidepressants (TCAs), 
investigated the long-term (8 years) selective serotonin-norepinephrine 
effects of glycemic control and reuptake inhibitors (SNRIs), calcium 
concluded that each 1% rise in A1C channel a6 ligands (gabapentin and 
level slows down nerve conduction pregabalin), and topical lidocaine. 

by 1.3 m/sec.* Importantly, however, Second-line medications include 
Stricter blood glucose control has tramadol and opioid analgesics. 
been shown to increase the risk of There are a variety of third-line 
severe hypoglycemic episodes.* As medications that include other 

a result, it is evident that glycemic antidepressants and anticonvulsants, 
control plays an important role in capsaicin, dextromethorphan, 
management of diabetic peripheral memantine and mexiletine.’ 


Describe the dosing strategy for a pharmacothera- Serotonin-norepinephrine reuptake 
inhibitors (SNRI) 


The American Academy of Neurology, 
the American Association of 
Neuromuscular and Electrodiagnostic 
Medicine, and the American 
Academy of Physical Medicine and 
Rehabilitation published “Evidence- 
based guideline: Treatment of painful 
diabetic neuropathy.”* They rated 
published clinical trials based on 
outcome measures. Their only Level A 
recommendation was pregabalin 300- 
600 mg/day. Level B recommendations 
were as follows: 


e Gabapentin 900-3,600 mg/day 

e Sodium valproate 500-1,200 mg/day 
e Venlafaxine 75-225 mg/day 

e Duloxetine 60-120 mg/day 

e Amitriptyline 25-100 mg/day 

e Dextromethorphan 400 mg/day 


e Morphine sulfate, titrated to 
120 mg/day 


e Tramadol 210 mg/day 


e Oxycodone mean dose 37 mg/day, 
maximum 120 mg/day 


e Capsaicin 0.075% four times daily 
e Isosorbide dinitrate spray 


e Electrical stimulation, percutaneous 
nerve stimulation for 3-4 weeks 


Interventions that were not recom- 
mended included oxcarbazepine, 
lamotrigine, lacosamide, clonidine, 
pentoxyfylline, mexiletine, magnetic 
field treatment, low-intensity laser 
therapy and Reiki therapy.® Let's take a 
closer look at the more common Level 
A and B recommendations. Dosing of 
commonly used agents is shown in 
Table 1. 


MARYLANDPHARMACIST.ORG i 21 


Calcium Channel a,6 Ligands 
(gabapentin and pregabalin) — 
Pregabalin and gabapentin bind to 
voltage-gated calcium channels at the 
a6 ligand, inhibiting neurotransmitter 
release. Pregabalin was shown to have 
a larger clinical dose-related effect 
than gabapentin in clinical trials of 
painful diabetic neuropathy, as well as 
enhancing quality of life.8 Pregabalin 
and gabapentin have few drug 
interactions, but both cause dose- 
dependent sedation and dizziness; 
therefore, doses should be started low 
and titrated carefully. 


Tricyclic Antidepressants 

(TCA) — TCAs block the reuptake 

of norepinephrine and serotonin, 
increasing levels of these neuro- 
transmitters in the synapse and 
promoting neuronal activity. The 
strongest efficacy data for treating 
painful diabetic neuropathy is seen 
with amitriptyline; evidence is weaker 
with desipramine, imipramine and 
nortriptyline.® TCAs frequently cause 
sedation, orthostatic hypotension and 
anticholinergic adverse effects (dry 
mouth, constipation, urinary retention, 
blurred vision, cognitive impairment).’ 
Doses are started low (10-25 mg at 


bedtime) and titrated slowly. Caution 
Should be used with patients with a 
history of ischemic cardiac disease or 
ventricular conduction abnormalities.’ 


Selective Serotonin- 
Norepinephrine Reuptake 
Inhibitors (SNRIs) — Duloxetine and 
venlafaxine have both been shown 
to be effective in treating the pain 

of diabetic peripheral neuropathy.® 
Since both agents are approved for 
depression, either of these agents are 
a reasonable choice when a patient 
has both depression and painful 
diabetic neuropathy. Doses should be 
Started low and titrated carefully to 


Table 1 * Comparison of first line therapies in the management of painful diabetic neuropathy 


CLASS 


SNRI 


Amitriptyline 
(Elavil, generic) 


100 mg) 


Nortriptyline 
(Pamelor, generic) 


100 mg) 


Duloxetine 
(Cymbalta) 


Venlafaxine 
(Effexor, generic) 


os as 


po q4h 


22 MB MARYLAND PHARMACIST | WINTES 


SD: 10-25 mg HS 
MDD: 150 mg (usually 
does not exceed 


SD: 30 mg (15 mg BID) 
MDD: 120 mg 
(60 mg BID; little benefit 
seen with doses above 
60 mg per day) 


SD: 37.5-70 mg 
(37.5 QD- BID) 
MDD: 225 mg 
(75 mg TID) 


SD: 150 mg (50 mg 
TID or 75 mg BID) 
MDD: 300 mg 


SD: 100-300 mg HS 
or TID MDD: 1800 mg 
(600 mg TID) 


SD: 25-50 mg four 
times daily 
MDD: 400 mg 


SD: 2.5-5 mg 


MDD: Should be 
individualized 


SD: starting dose « MDD: maximum daily dose « HS: bed time © QD: one daily « BID: twice a day ¢ TID: three times a day ¢ BBW: black box warning 


Dry mouth, constipation, 
weight gain, somnolence, 
dizziness, urinary retention, 
blurred vision. arrhythmias, 
heart block, QT prolongation. 


Nausea, drowsiness, 
dizziness, dry mouth, 
constipation, blurred 
vision, anorexia, 
nervousness, insomnia, 
sweating, yawning. 


Peripheral edema, 
dizziness, somnolence, 
difficulty concentrating, 
blurred/double vision, 

dry mouth, weight gain, 
loss of coordination. 


Nausea, vomiting, 


Start low, titrate slowly. 
Serotonin syndrome. 


Abrupt discontinuation 
should be avoided, 
suicidal thoughts, 
bipolar disorder, 
hepatic and renal 
impairment. Serotonin 
syndrome. 


Abrupt discontinuation, 
renal impairment, 
peripheral edema/CHF, 
suicidal behaior or 
ideation. 


Renal and hepatic 


constipation, impairment, seizures, 
lightheadedness, do not use with suicidal 
dizziness, drowsiness, ideation. Caution with 
confusion. history of drug abuse/ 
habituation. 


MEDICATION COMMON SIDE PRECAUTION COMMENTS 
EFFECTS 


SD: 10-25 mg HS 
MDD: 150 mg (usually 
does not exceed 


Amitriptyline has more 
anticholinergic side 
effects. 


BBW: Patients should be 
monitored for worsening 
and emergence of 
Suicidal thoughts and 
behaviors. 


Cases of Stevens- 

Johnson syndrome 
have been reported 
with gabapentin. 


Serotonin syndrome. 


Consider long-acting 
formulation after 
optimal total daily 
dose achieved. 


avoid adverse effects such as nausea 
with duloxetine. Venlafaxine can cause 
cardiac conduction abnormalities and 
hypertension, and therefore should 
be used with caution in patients with 
a cardiac history. It is important that 
patients remain adherent to therapy, 
particularly with venlafaxine, which 
can cause withdrawal symptoms with 
missed doses or sudden cessation 

of therapy.’ 


Opioids — Opioids such as morphine, 
oxycodone and tramadol are 
considered second-line in general 

for the management of neuropathic 
pain, and considered Level B options 
by the AAN guidelines.”® The IASP 
guidelines acknowledge that opioids 
may be considered a first-line option 
when more rapid pain relief is needed, 
or while titrating an alternate agent 
to achieve the target dose.’ Of course 
practitioners must be mindful of the 
risks of opioid therapy, and patients 
should be screened for potential drug 
abuse or misuse. 


Combination Pharmacotherapy 
—|n order to maximize therapeutic 
outcomes and minimize drug-induced 
adverse effects of drugs used in 


DR is a 54 year old morbidly obese 
woman who has a history of type 2 
diabetes, osteoarthritis, chronic kidney 
disease, and chronic constipation. She 
presents for her quarterly visit with her 
primary care provider. 


CC/HPI 


DR’s only complaint today is “this jabbing 
pain in my feet that has been getting worse 
over the past few months.” 


She describes her pain as numbness and 
pain in the distal aspect of the calves and 
feet, which she says is much worse at 
night when she tries to sleep. She scores 
her pain as a 5 during the day, 9 at night. 
She describes the pain as though her feet 
were “freezing cold like walking barefooted 
in the snow, with someone jabbing pins 
and needles into me.” At times she recalls 
feeling electrical shocks and tingling. She 
had previously been active in her church 
(delivering meals for homebound patients) 
and gardening. She states her feet hurt so 


management of neuropathic pain, it 
may be worth considering rational 
polypharmacotherapy. Combination 
of two or more drugs with different 
mechanisms of actions at lower doses 
has been proven to be an effective 
Strategy. For instance, lower doses 

of pregabalin could be combined 

with nortriptyline to control the pain 
more effectively while reducing side 
effects. These two coanalgesics act by 
different mechanisms of action which 
can enhance therapeutic outcomes, 
while causing fewer dose-related 
adverse effects. In a randomized 
controlled trial the combination of 
nortriptyline and gabapentin was 
shown to be superior when compared 
to the effects of either medication 
administered alone in a higher dose.’ 
Although polypharmacy is traditionally 
discouraged, in pain management this 
strategy could result in added benefits 
and lower adverse effects when dosed 
and monitoring carefully." 


In summary, the best management 
strategy to prevent or slow the 
progression of painful diabetic 
neuropathy is improved blood 
glucose control for patients with 


badly when she stands or walks that she 
cannot participate in these activities any 
longer. 


She had tried acetaminophen to control her 
osteoarthritis (of both knees) pain. She had 
increased the acetaminophen to 1000 mg 
q4h to try to treat the pain in her feet/calves 
but she did not achieve any pain relief, and 
her community pharmacist advised her 

to reduce her acetaminophen total daily 
dose to 4 grams or less. She tried a friend's 
over-the-counter naproxen for the foot/ 
calf pain but it upset her stomach. She also 
tried a friend's diclofenac topical cream but 
stopped using the cream because it didn’t 
help her foot pain. 


The patient describes feeling very unhappy 
about this pain, as well as having difficulty 
sleeping. She told her physician she was 
very distressed by her lot in life, and he 
suggested she start a walking program 
because “exercise improves everything.” 
She denies any history of mental illness or 


diabetes, while using caution to 

avoid hypoglycemia. Patients 

with diabetes should receive 
comprehensive counseling about 

skin and foot care, the selection of 
footware, and daily inspection of 
hyposensitive areas and pressure 
points of the feet. Non-pharmacologic 
interventions are an important 

part of chronic pain management, 
possibly including percutaneous 
electrical nerve stimulation. 
Pharmacologic interventions generally 
include selected antidepressants, 
anticonvulsants or other agents, alone 
or in rational combinations. 


Pharmacists have an important role to 
play in the education of patients about 
the use of these coanalgesics to treat 
pain, including explaining that they are 
not being used to treat depression or 
epilepsy respectively, but have been 
shown to have analgesic properties. 
Another important counseling point 

is that when antidepressants and 
anticonvulsants are used to treat 
neuropathic pain adherence to 
therapy is important; these are not 
“orn” medications to be used only 
when the patient experiences pain. 


substance abuse but is concerned about 
using “narcotics” to control her pain 
because of media reports about people 
abusing these medications and the risk she 
might have of becoming addicted to them. 


PMH 


Patient has a history of osteoarthritis for 
about 10 years, affecting both knees, right 
more than left. Pain present constantly, 
worse with weather changes, after sitting 
for more than 20-30 minutes, and when 
ascending stairs. She rates this pain as an 
average of 5 (on a 0-10 scale), best of 3 and 
worst of 7. 


Diagnosed with type 2 diabetes about 

15 years ago. Her diabetes is treated 

with recommended diet and exercise 

(she doesn’t follow lifestyle modification 
recommendations; patient states she is 
“addicted to carbohydrates” and exercise 
hurts her knees) and glipizide. 


History of chronic kidney disease for 3 years. 


MARYLANDPHARMACIST.ORG ff 23 


She complains of difficulty having bowel 
movements. She would like to achieve 

a bowel movement daily, but it's more 
commonly 3-4 times a week and she has to 
exert considerable straining. 


CURRENT MEDICATIONS 


Glipizide 10 mg po bid 


Acarbose 50 mg po three times daily 
(patient does not take this medication due 
to abdominal pain and gas production) 


Acetaminophen 1000 mg by mouth every 6 
hours 


Calcium + D one tablet per day 


ALLERGIES/PREVIOUS ADR’S 


No known allergies to medications 


VACCINES 


Up to date with childhood vaccinations; 
current with flu vaccine and Zostavax 


Health maintenance: up to date with 
pap smear and performs monthly breast 
examinations 


SOCIAL HISTORY 


Smoking: Quit about 4 years ago 


Alcohol: denies, except for one cocktail 
around the holidays 


Illicit drug use: Denies 


What is the diagnosis of DR’s 
problem? 


DR most likely has moderately-severe 
painful diabetic neuropathy. 


What is the therapeutic objective to 
treat DR’s problem? 


To relieve the pain to a level she 
finds acceptable, to allow DR to 
perform her desired activities of daily 
living (church activities, gardening, 
be able to sleep, relieve feelings of 
irritability and depression), prevent 
disease progression and prevent 
complications of diabetic neuropathy. 


24 MH MARYLAND PHARMACIST | 


ROS 


GU — history of chronic kidney disease; 
denies painful urination, nocturia, urinary 
retention or increase in urinary frequency 


Gl — difficulty having bowel movements 
as described in HPI. Denies diarrhea, rectal 
pain or bleeding. 


Endocrine — denies appetite changes, cold 
intolerance, polyuria, polydipsia, polyphagia 


Neuropsych — Positive for anhedonia, 
depressed mood, reduced sleep, decreased 
energy. Negative for suicidal thoughts, 
feelings of guilt or worthlessness 


PHYSICAL EXAM 


Ht/Wt: 5'4",285 pounds 


Vital signs: BP 140/84 mmHg, HR 88 bpm, 
RR 16, T 98.6 


General: Well-developed, morbidly obese 


Ext/Neuro: Abnormalities of the peripheral 
nervous system, skin and vascular supply for 
her distal lower extremities observed. Skin 
of her feet is shiny and thin, with a bluish 
coloration, and feet are cool to the touch. 
Pulses in feet are bilaterally diminished 
but symmetrical. Lower extremity strength 
testing is 5/5. Deep tendon reflexes are 
diminished at the ankles (1/4) relative to 
the knees (2/4) bilaterally. Sharp, thermal, 
and vibration sensations are absent from 
midcalves distally, and placement of the 
cool tuning fork directly against her feet 
caused an increase in her pain level. She 
has difficulty heel walking. Bilateral pitting 
edema (1+). 


What patient- and drug-related 
variables should you consider before 
making a recommendation for DR? 


Patient-related considerations include 
history of renal impairment (serum 
creatinine 1.4 mg/dl; creatinine clearance 
approximately 35 ml/min), health beliefs 
(doesn't want an opioid), history of 
diabetes and history of edema. 


Agent-related considerations include need 
to dose adjust based on renal function 
(e.g., pregabalin, gabapentin), valproic 
acid worsens blood glucose, pregabalin is 
rated Level A, venlafaxine and duloxetine 
also treat depression. 


Neuropsych: Scored 16 on a Beck 
Depression Inventory-II 


LABORATORY DATA 


A1c 9.6 (8.8 six months ago) 


Sodium 140, Potassium 4.2, Chloride 100, 
carbon dioxide 25, serum creatinine 1.4, 
BUN 28, glucose (random) 224 


REFERENCES 


1. Tesfaye S, Selvarajah D. Advances in the epidemiology, pathogenesis and 
management of diabetic peripheral neuropathy. Diabetes Metab Res Rev 


2012;28 (suppl 1):8-14. 


2. Hartemann A, Attal N, Bouhassira D, et al. The Working Group on the 
Diabetic Foot from the French-speaking Society of Diabetology (SFD). 
Painful diabetic neuropathy: Diagnosis and management. Diabetes 
&Metabolism 2011;37:377 


3. Diabetic Neuropathy [Internet]. Minnesota: Mayo Foundation for 
Medical Education and Research; c2005 [Updated 2012 Mar 6; cited 
2013 Aug 28]. Available from: http://www.mayoclinic.com/health/ 
diabetic-neuropathy/DS01045 


4. Callaghan BC, Little AA, Feldman EL, Hughes RA. Enhanced glucose 
control for preventing and treating diabetic neuropathy. Cochrane 
Database Syst Rev. 2012 Jun 13; 6:CD007543 


5. Said G. Diabetic neuropathy—a review. Nature Clinical Practice 
Neurology (2007) 3, 331-340. 


6. Amthor KF, Dahl-Jargensen K, Berg TJ, Heier MS, Sandvik L, Aagenaes O, 


Hanssen KF. The effect of 8 years of strict glycaemic control on peripheral 


nerve function in IDDM patients: the Oslo Study. Diabetologia. 1994 
Jun;37(6):579-84, 


7. Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the 
pharmacological management of neuropathic pain: An overview and 
literature update. Mayo Clin Proc 2010;85(3 suppl):S3-S14. 


8. Bril V, England J, Franklin GM et al. Evidence-based guideline: Treatment 
of painful diabetic neuropathy. Neurology 2011;76:1-1. 


9. Gilron |, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL. 
Nortriptyline and gabapentin, alone and in combination for neuropathic 
pain: a double-blind, randomized controlled crossover trial. Lancet. 
2009;374:1252-1261. 


10. Christine Rhodes. Update on Therapies for Neuropathic Pain. New York: 
The Pain Practitioner: 2011;21(3):44-47. 


11. Facts and Comparisons eAnswers. 2013 Wolters Kluwer Health, Inc. 
Accessed online at: http://online.factsandcomparisons.com.proxy-hs. 
researchport.umd.edu/index.aspx. Accessed December 20, 2013. 


12. WebMD. 2005-2013 WebMD, LLC. Accessed online at: http://www. 
webmd.com/drugs/index-drugs.aspx. Accessed December 20, 2013. 


What do you recommend to treat DR’s 
complaint? 


Duloxetine (Cymbalta) 30 mg by mouth 
once daily. After one week increase to 60 
mg by mouth once daily (provided patient 
is nausea-free). Hopefully this will help 
with the painful diabetic neuropathy, and 
her depression. If a second analgesic is 
needed, consider adding pregabalin or 
gabapentin. 


CONTINUING EDUCATION continued 


CONTINUING EDUCATION QUIZ 


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Education as a provider of continuing ; Neuropathy can be found online at www.PharmCon. 


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MARYLANDPHARMACIST.ORG ff 25 


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